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A  TEXT-BOOI 


x. 


DENTAL  PATHOLOGI 

AND 

THERAPEUTICS 


FOR  STUDENTS  AND  PRACTITIONERS 


BASED    rPOX   THE    ORIGIXAL    OF 

HENRY  H.  BURCHARD,  M.D.,  D.D.S. 

LATE    SPECIAL   LECTURER   OX   DENTAL   PATHOLOGY    AND   THERAPEUTICS    IN    THE    PHILADELPHI.1 

DEXTAL   COLLEGE 


REWRITTEN  BY 

OTTO  E.  INGLIS,  D.D.S. 

PROFESSOR    OF   DEXTAL  PATHOLOGY  AND  THERAPEUTICS  IX   THE    PHILADELPHIA 
DEXTAL   COLLEGE 


SIXTH  EDITION,  THOROUGHLY  REVISED 


ILLUSTRATED   WITH    735    ENGRAVINGS   AND    A    COLORED    PLATE 


T 


LEA  &  FEBIGER 

PHILADELPHIA    AND    NEW   YORK 

1920 


Copyright 

LEA  &   FEBIGER 

1920 


THIS 

V  O  L  U  M  E 

IS    RESPECTFULLY    DEDICATED 

TO 

RUSSELL  H.  CONWELL,  D.D.,  LL.D. 

IN    RECOGNITIOX    OF    HIS    UNSELFISH 

EFFORTS    IX    THE 

OPENING    OF    OPPORTUNITIES 

FOR    EDUCATION. 


PEEFACE  TO  SIXTH  EDITION. 


In  re^-ising  this  work  for  a  new  edition,  the  editor  has  endeav- 
ored to  maintain  the  original  idea  of  a  text-book,  furnishing  a 
description  of  each  dental  disease  and  its  treatment  in  such  manner 
that  teachers  may  find  it  a  useful  adjunct  in  the  presentation  of 
the  subject  of  dental  pathology  and  therapeutics  to  their  students. 
Since  the  last  edition  a  reprint  has  been  necessary,  owing  to  an  unex- 
pectedly large  demand  by  the  Government,  and  in  consequence  of 
this  and  the  almost  revolutionary  changes  which  have  occurred 
in  the  professional  thought  and  because  of  natural  de^•elopments 
from  scientific  investigations  many  changes  have  had  to  be  made. 
It  has  been  thought  advisable  to  omit  certain  chapters  dealing 
with  subjects  which  are  better  covered  in  other  approved  text- 
books and  to  include  new  chapters  upon  subjects  which  are 
germane  to  dental  pathology.  Thus,  chapters  on  Prophylaxis, 
Radiography,  Plantations,  The  Uses  of  Electricity  in  Therapeutics 
and  Root  Amputation  have  been  inserted.  ]Many  new  illustra- 
tions have  been  added  to  take  the  place  of  some  omitted  and  to 
enhance  the  elucidation  of  the  subjects. 

Wherever  quotations  appear  an  endeavor  has  been  made  to  credit 
the  author,  the  idea  to  be  presented  has  been  the  compelling 
motive  rather  than  the  writing  of  a  history.  Quotations  have 
generally  been  made  from  current  literature  and  from  as  limited 
a  bibliography  as  possible  in  order  that  this  work  may  have  value 
added  to  it  by  reference  to  books  and  journals  within  easy  reach 
of  any  who  desire  further  details.  The  editor  desires  to  thank 
those  who  have  kindly  loaned  illustrations,  and  the  publishers  for 
their  generous  treatment,  also  the  profession  for  its  continued 
favor.  O.  E.  Inglis. 

1524  Chestnut   Street,   Philadelphia. 


CO^CTEXTS. 

SECTION    I. 
GENERAL   PATHOLOGY. 

CHAPTER   I. 
Gexeral  Principles 17 

CHAPTER  II. 

Disturbances  of  the  Vascular  System 21 


SECTION    II. 
ABERRATIONS  IN  ERUPTION  OF  THE  TEETH.       . 

CHAPTER  III.  » 

Dentition:     Its  Progress,  Variations,  ant)  Attendant  Disorders     .       63 

CHAPTER  IV. 

Malformation  ant)  Impaction  of  Teeth 115 


SECTION   III. 
DEVELOPMENTAL  ABNOR DUALITIES. 

CHAPTER  V. 

Malformations  and  Anomalies  of  the  Teeth 133 


SECTION    IV. 

ACQUIRED  NON-SEPTIC  AFFECTIONS  OF  THE  ENA:MEL 

AND  DENTIN. 

CHAPTER   VI. 
Abrasion,  Erosion,  and  Mechanical  Injury 199 

CHAPTER   VII. 
Stains  of  the  Enamel  ant)  Dentin 232 


^.jii  CONTENTS 


SECTION    V. 
DENTAL  CARIES  AND  HYPERSENSITIVE  DENTIN. 

CHAPTER  VIII 
Dental  Caries:  History;  Exciting  and  Predisposing  Causes       .      .     241 

CHAPTER  IX. 
Dental  Caries:  Pathology,  Morbid  Anatomy,  and  Clinical  History     273 

CHAPTER  X. 

Dental  Caries:  Diagnosis,  Symptoms,  and  Prognosis 301 

CHAPTER  XI. 
Dental  Caries:  Therapeutics  and  Prophylaxis 337 


SECTION   VL 
DISEASES  OF  THE  DENTAL  PULP. 

CHAPTER  XII. 
Constructive  Diseases 359 

CHAPTER  XIII. 

Destructive  Diseases  of  the  Dental  Pulp    .      .      .      .      .      .      .      .     380 

CHAPTER  XIV. 
Methods  of  Removal  of  the  Dental  Pulp  and  Root-canal  Filling     428 

CHAPTER  XV. 
Gangrene  of  the  Pulp 481 


SECTION  VII. 
DISEASES  OF  THE  PERICEMENTUM. 

CHAPTER  XVI. 
Pericementitis 511 


CONTENTS  ix 

CHAPTER  XVII. 
Chronic  Septic  Apical  Pericementitis 535 

CHAPTER   XVIII. 
Non-septic  Pericementitis 56S 


SECTION  VIII. 

PERICEMENTAL  DISEASES  BEGINNING  AT  THE 
GUM  MARGIN. 

CHAPTER  XIX. 
Gingivitis 603 

CHAPTER  XX. 

Salivary  and  Serumal  Calculus 628 

CHAPTER  XXI. 

Pyorrhea  Alveolaris 649 

CHAPTER  XXII. 
Pericemental  Abscess 698 

CHAPTER  XXIII. 

Reflex  Neuroses 705 

CHAPTER  XXIV. 

Infections  of  and  from  the  IMouth,  and  Sterilization     ....      719 

CHAPTER  XXV. 

Prophylaxis 747 

CHAPTER  XXVI. 
,  Dental  Radiography^ 761 

'  CHAPTER  XXVII. 
Apicoectomy  and  Root  Amputation 771 

CHAPTER  XXVIII. 

Plantation  of  Teeth 777 

CHAPTER  XXIX. 

The   Uses  of  Electricity  in  Dental  Therapeutics 783 

CHAPTER  XXX. 

Asepsis  and  Sterilization 793 


DENTAL  PATHOLOGY  AND  THERAPEUTICS. 


SECTION   I. 

GENERAL  PATHOLOGY. 


CHAPTER  I. 
GENERAL  PRINCIPLES. 

General  pathology  (pathos,  disease,  and  logos,  a  discourse)  is  that 
branch  of  science  which  treats  of  the  modifications  in  function  and 
changes  in  structure  occurring  in  disease.  It  embraces  all  patho- 
logical processes  occurring  in  the  human  body,  and  as  many  of  these 
occur  in  and  about  the  teeth,  modified  only  by  the  peculiar  anatomy 
of  the  parts,  Dental  Pathology  may  be  said  to  be  that  branch  of 
dental  science  which  treats  of  modifications  in  function  and  changes 
in  structure  occurring  in  the  diseases  of  the  teeth  and  associate  parts. 

This  being  true,  it  follows  that  the  study  of  dental  pathology  must 
be  preceded  by  a  study  of  the  general  disease  processes  which  affect 
the  tissues  of  the  body,  and  such  of  these  as  are  applicable  to  the 
study  are  known  as  the  General  Principles. 

The  word  Therapeutics  is  derived  from  the  Greek  therapeuein,  to 
take  care  of,  meaning  the  measures  adopted  to  remedy  or  remove 
the  changes  induced  by  pathological  processes. 

The  study  of  the  pathology  of  a  part  begins  with  a  study  of  its 
anatomy  and  histology,  then  naturally  follows  a  study  of  its  physi- 
ology and  embryology.  These  form  the  basis  from  which  degrees 
of  abnormal  function  and  altered  structure  may  be  judged  by  com- 
parison with  similar  processes  occurring  in  other  parts  of  the  body. 

This  altered  function  and  structure  theoretically  go  hand  in  hand, 
as  whichever  begins  first  the  other  surely  follows  even  if  only  to  a 
microscopic  degree.  Disease,  in  its  broad  sense,  is  therefore  an  altera- 
tion of  nutrition,  resulting  in  changes  in  function  and  structure. 
The  term  Disease  refers  to  the  various  classified  pathological  con- 
2  (17) 


18  GENERAL  PRINCIPLES 

ditions,  each  occurring  in  a  more  or  less  definite  way  and  having 
sufficiently  defined  characteristics  to  render  them  distinct  from  each 
other.  The  sequence  of  cause,  effect  upon  the  circulation  and  the  cells, 
the  alterations  in  the  function  and  structure  of  the  cells  and  of  the 
part  or  body  as  a  whole,  together  with  the  terminations  of  disease, 
are  embraced  in  the  term  Pathology.  The  term  iMorbid  Anatomy 
refers  more  particularly  to  the  changes  in  structure. 

A  disease  cause  may  be  defined  as  any  influence  of  whatsoever 
nature  which  is  capable  of  disturbing  the  nutritive  balance  of  any 
portion  of  the  body. 

The  study  of  disease  causes  is  called  Etiology.  The  signs  of 
disease  obtamable  by  vision,  hearing,  touch,  smell,  taste,  micro- 
scopic examination  or  chemical  analysis  are  termed  the  Objective 
Symptoms.  Such  sensations  or  effects  as  are  described  by  the 
patient  are  the  Subjecti^'e  Symptoms.  The  study  of  both  kinds  is 
S\'mptomatology. 

The  grouping  of  all  the  clinical  phenomena  of  a  particular  disease 
is  its  Clinical  History. 

The  distinction  of  a  present  disease  from  all  others  by  means  of 
its  symptoms  is  Diagnosis,  and  its  probable  outcome  judged  from  the 
existing  phenomena  and  the  usual  clinical  history  under  such  circum- 
stances is  Prognosis. 

The  cause  which  directly  produces  a  disease  is  kno\^Tl  as  the  excit- 
ing cause,  while  a  condition,  either  local  or  systemic,  which  favors  its 
action  is  kno\Mi  as  a  predisposing  cause  (see  those  of  Dental  Caries). 
A  Proximate  Exciting  Cause  is  one  which  exerts  its  effect  directly 
upon  the  cells,  whilea  cause  back  of  this  and  to  which  the  proximate 
cause  may  be  due,  is  a  Primary  Exciting  Cause. 

The  proximate  exciting  causes  may  be  conveniently  grouped  into: 

1.  Abnormal  Food  Supply,  a  condition  of  the  blood  which  contains 
substances  improper  for  the  cells,  or  lacks  constituents  they  need,  or 
the  cells  are  supplied  with  too  much  or  too  little  hmiph  (food). 

2.  Abnormal  Waste  Removal,  either  due  to  circulatory  disturbance 
causing  retention  of  the  waste  of  cells  about  them  when  it  should  be 
removed,  or  as  a  fault  of  som.e  excretory  organ  (primarv  cause) 
retaining  waste  of  cells  in  the  blood  as  a  whole. 

3.  Abnormal  Physical  Conditions,  such  as  direct  injuries,  mechani- 
cal mterference  with  the  cells  or  their  circulation,  or  chemical  effects 
mcluding  the  action  of  microorganisms. 

_  4.  A})normal  Nerve  Supply,  such  as  excessive  or  defective  innerva- 
tion. 

lu  a  general  way  all  living  cells,  includmg  microorganisms,  have 
common  life  conditions  which  may  be  grouped  as  follows: 


PATHOGENESIS  19 

1.  A  proper  food  supply,  including  water  and  oxygen,  though 
some  bacteria  seem  to  do  better  in  the  absence  of  oxygen  and  plants 
require  carbon  dioxid. 

2.  A  proper  removal  of  waste  products. 

3.  Proper  physical  conditions,  including  a  proper  temperature. 

4.  Possibly  a  proper  innervation,  though  this  does  not  apply  to 
microorganisms. 

As  disease  conditions  are  alterations  of  nutrition,  due  mainly  to 
change  in  life  conditions,  the  above  classification  of  proximate 
exciting  causes  is  justifiable. 

From  the  standpoint  of  dental  pathology,  exciting  causes  may  again 
be  di\'ided  into  (1)  septic  or  those  due  to  bacteria  or  protozoa  and 

(2)  aseptic  or  non-septic,  such  as  the  mechanical,  chemical  and  ner- 
vous, the  resulting  diseases  being  also  broadly  classifiable  into  septic 
and  non-septic,  each  class  having  many  dental  representatives. 

In  the  production  of  pathological  conditions  by  a  disease  cause 
the  part  may  (1)  be  injured  directly  after  which  the  process  of  pathol- 
ogy starts  in  the  tissue  injured  if  death  of  all  cells  be  not  immediately 
produced,  but  if  death  of  cells  occurs,  the  process  begins  in  the  adjoin- 
ing living  cells  or  (2)  the  cells  may  be  stimulated,  all  their  functions 
being  increased  either  within  semi-physiological  bounds  or  stimulated 
to  the  point  of  weariness  and  exhaustion.  The  substance  of  the  cells 
is  lost  in  overwork,  and  if  not  promptly  replaced,  degeneration  ensues. 

(3)  The  cells  may  be  reduced  in  activity  by  lessened  temperatures, 
retained  waste  products  or  lack  of  food  supply,  lessened  innervation, 
etc.,  and  all  of  their  functions  reduced.  They  gradually  pass  through 
atrophy,  degeneration  and  death,  owing  to  altered  metabolism.  (4) 
Cells  may  be  altered  m  character  by  infiltration  of  materials  derived 
from  other  sources  into  their  substance  or  they  may  be  individually 
injured  by  microorganisms. 

The  origin  and  progress  (Pathogenesis)  of  a  disease  being  known, 
intelligent  efforts  may  be  made  for  its  prevention.  This  is  Prophy- 
laxis. 

The  science  of  prevention  of  disease  upon  the  broad  basis  of  a 
knowledge  of  disease  causes  and  observance  of  laws  of  health  is 
Hygiene. 

It  will  be  seen  that  a  knowledge  of  special  pathology  can  only  be 
obtained  from  (1)  a  knowledge  of  pathology  in  general  or  at  least  of 
those  principles  of  general  pathology  which  underlie  all  disease  pro- 
cesses; (2)  a  knowledge  of  the  local  anatomy  and  histology;  (3)  a 
knowledge  of  local  embryology  and  physiology;  (4)  a  study  of  local 
pathology  and  morbid  anatomy.  To  this  must  be  added  a  study  of 
materia  medica  and  special  therapeutics. 


20  GENERAL  PRINCIPLES 

When  treatment  is  based  on  pathogenesis  and  a  parallel  knowledge 
of  the  action  of  drugs  and  remedies,  it  is  termed  Rational  Thera- 
peutics. ■  When  based  upon  known  good  effects  of  a  drug  or  remedy, 
without  knowledge  of  its  action,  it  is  termed  Empirical  Thera- 
peutics. 

In  this  work  merely  the  most  important  general  principles  are 
included,  the  reader  being  referred  to  works  on  general  pathology 
for  subjects  not  touched  upon. 


r 


FigUI 


rcff.vm. 


6        c    a! 


^    ^    A        '        J  k      I        m 


Oft  A  *VNOYJ.NZ  CMASe 


BLOOD. 

(Ehrlich  triple  stain.) 
(Prepared  by  Dh.  I.  P.  Lton.) 

Fiy.  I.     TYPES    OF   LEUCOCYTES. 

a.  Polymorphonueiear  Neutrophile.  b.  Polymorphonuolear  Eosinophile.  c.  Myelocyte 
(Neutrophilic),  d.  Sosinophilie  Myelocyte,  e.  Large  Lymphocyte  (large  Mononuclear). 
/.  Small  Lymphocyte  (small  Mononuclear). 

Fig.  II.     NORMAL   BLOOZ!, 
Field  contains  one  neutrophile.     Reds  are  normal. 

Fig.  III.    ANEMIA,  POST-OPERATIVE  (secondary). 

The  reds  are  fewor  than,  normal,  and  are  deficient  in  hsemoglobin  and  some'what 
irregular  in  form.  One  normoblast  is  seen  in  the  field,  and  t'wo  neutrophiles  and  oni9 
small  lymphocyte,  showing  a  marked  post-hsemorrhagic  anaemia,  with  leueocytosis. 

-Fig.  IV.     LEUCOCYTOSIS,  INFLAMMATORY. 

The  reds  are  normal.  A  marked  leueocytosis  is  shown,  with  five  neutrophiles  and 
one  small  lymphocyte.  This  illustration  may  also  serve  the  purpose  of  show^ing  the 
leueocytosis  of  malignant  tumcp. 

Fig.  V.     TRICHINOSIS. 
A  marked  leueocytosis  is  shown,  consisting  of  an  eosinophilia. 

Fig.  VI.     LYMPHATIC  LEUKEMIA. 

Slight  anaemia.  A  large  relative  and  absolute  increase  of  the  lymphocytes  (chiefly 
the  small  lymphocytes)  is  shown. 

Fig.  VII.     SPLENO-MYELOGENOUS   LEUKEMIA. 

The  reds  show  a  secondary  anaemia.  Two  normoblasts  are  shown.  The  leueocytosis 
is  massive.  Twenty  leucocytes  are  shown,  consisting  of  nine  neutrophiles,  seven  myelo- 
cytes, two  small  lymphocytes,  one  eosinophile  (polymorphonuclear)  and  one  eosinophilic 
myelocyte.  Note  the  polymorphous  condition  of  the  leucocytes,  i.e.,  their  variations 
from  the  typical  in  size  and  form. 

Fig.  VIII.     VARIETIES   OF   RED    CORPUSCLES. 

a.  Normal  Red  Corpuscle  (normocyte).  b,c.  Anaemic  Red  Corpuscles,  d-g.  Poikilocytes. 
h.  Microcyte.  i.  Megaloeyte.  j-n.  Nucleated  Red  Corpuscles.  j,k.  Normoblasts.  I.  Micro- 
blast.    Tii,n.  Megaloblasts. 


CHAPTER  II. 
DISTURBANCES  OF  THE  VASCULAR  SYSTEM. 


A  SUITABLE  amount  and  quality  of  blood  normally  flows  through 
the  arteries,  capillaries  and  veins,  and  is  in  close  relation  to  processes 
of  nutrition  occurring  in  the  lymph  channels  or  adjunct  circulatory 
apparatus. 

The  amount  of  blood  in  the  vessels  may  be  increased  (plethora), 
though  not  permanently.  It  may  be  decreased  rapidly  in  quantity, 
as  by  hemorrhage,  or  its  red  corpuscles  may  be  gradually  lessened 
in  number  (acute  or  chronic  anemia).  The  proportion  of  white  cor- 
puscles to  red  ones  may  be  increased  abnormally  (leukemia).  The 
hemoglobin  of  red  corpuscles  may  be  deficient  (chlorosis).  Locally 
the  amount  of  blood  in  a  part  may  be  increased  (hyperemia  or 
inflammation)  or  diminished  (ischemia). 

Normally  the  blood  contains  floating  in  the  plasma  5,000,000  red 
corpuscles,  or  erythrocytes,  and  from  5000  to  10,000  (1  to  500  red) 
white  corpuscles,  or  leukocytes,  to  each  cubic  millimeter.  (See  Plate, 
Fig.  II.)  A  marked  increase  in  the  number  of  erythrocytes  is  termed 
polycythemia;  a  marked  decrease,  oligocythemia.  The  temporary 
increase  in  number  of  white  corpuscles  is  leukocytosis,  a  temporary 
fall  is  leukopenia;   a  persistent  increase,  leukocythemia  or  leukemia. 

The  blood  corpuscles  may  be  classified  as  follows: 

See  Plate, 
Fig.  1  Fig.  VIII 

Normocytes  (normal  size)  .      .      .      .     1,  2, 3, 4.  a 


Erythjocj'tes      (non-nu- 
cleated red  corpuscles) 


Normal  to 
blood. 

Pathological 
indicators. 


Microcj'tes  (small  size) h 

Macrocj'tes  (large  size) 

Megalocytes  (very  large  size) » 

Poikilocytes  (irregular  form) d  e  f  g 


Erj'throblasts  (nucleated  f 
red  corpuscles  derived  I  Pathological 
from  red   marrow     of  1       indicators, 
bones)  .      .      .      .  [ 


Normoblasts  (normal  size) 
Microblasts  (small  size) 
Megaloblasts  (large  size)     . 


jk 


See  Plate, 


Leukocytes 
puscles) 


(white   cor- 


Fig. 

i  Lymphocytes  (small) 22% 
LjTnphocytes  (large) 6  " 
Polymorphonuclear  neutrophil es  .  .  70  " 
Polymorphonuclear  eosinophiles        .      .      2 " 

T>  j^i_   1     ■     if  Basophilic  leukocytes  or  mast  cells. 
Pathological  K,t  ,  -,- 

.    J.     ^         -!  Neutrophilic  myeloc\i:es  from  bone-marrow  . 

indicators.  .      ^  "'        '' 

^  tjOsinophuic  myelocytes 


Fig.  I 

/ 


(21) 


22 


DISTURBANCES  OF  THE   VASCULAR  SYSTEM 
Fig.   1 


Normal  blood  (triacid  stain):  1,  normal  red  cell,  flatly  spread  and  evenly  stained; 
2,  normal  rouleau;  3,  normal  red  cells  varying  slightly  in  size,  thickly  spread,  show- 
ing central  clear  areas;  4,  normal  red  cell,  of  slightly  altered  shape;  5,  lymphocyte, 
medium  size;  6,  large  mononuclear  leukocyte,  incurved  nucleus;  7,  polynuclear 
neutrophile  leukocyte;  8,  eosinophile  leukocyte.  Separate  nuclear  lobes.  (Schmaus 
and  Ewing.) 

ANEMIA. 

Anemia  is  a  condition  in  which  the  blood  is  lessened  in  quantity 
or  partly  deprived  of  its  essential  constituents — i.  e.,  red  corpuscles 
and  hemoglobin — in  consequence  of  which  the  tissues  receive  less 
oxygen  and  the  general  nutrition  is  impaired. 

Acute  Traumatic  Anemia  occurs  as  a  result  of  copious  hemor- 
rhage. The  individual  becomes  temporarily  pale  and  weak.  The 
arterial  pressure  is  lessened,  the  circulation  slowed,  and  the  pulse 
is  frequent  and  small.  Recovery  is,  as  a  rule,  prompt,  the  water 
being  first  restored  and  later  the  corpuscles  being  regenerated.^ 
Frequent  hemorrhages  cause  the  blood  to  become  watery  and  debility 
results  from  impaired  nutrition.    (See  Plate,  Fig.  III.) 

1  Ziegler,  General  Pathology. 


ANEMIA  23 

Symptomatic  Anemia. — A  diminution  in  the  number  of  red  cor- 
puscles may  occur  as  a  result  of  protracted  overwork,  anxiety,  study, 
or  long-continued  illness,  such  as  a  fever. 

The  number  of  red  blood  corpuscles  may  be  reduced  to  one-half  the 
normal  amount,  and  there  is  a  corresponding  debility.  The  condition 
may  disappear  with  appropriate  removal  of  the  cause. 

Chlorosis. — This  is  a  form  of  anemia  occurring,  for  the  most  part, 
in  girls  and  young  women,  and  characterized  by  a  great  deficiency 
in  the  hemoglobin  of  the  red  corpuscles  without  a  corresponding 
reduction  in  the  number  of  the  red  corpuscles.  In  the  watery  blood 
very  small  red  corpuscles  (microcytes)  are  seen;  also  a  few  very 
large  ones  (macrocytes),  and  some  of  irregular  outline  (poikilocytes).^ 
Myelocytes  are  occasionally  seen.  (Stengel.)  The  pathology  is 
uncertain.  If  prolonged,  the  red  corpuscles  may  sink  in  numbers 
to  3,000,000  or  2,000,000  per  cubic  millimeter  and  20  per  cent,  of 
hemoglobin. 

Being,  as  a  rule,  readily  cured  by  a  course  of  iron,  it  is  inferred 
that  the  body  is  starved  of  iron,  an  essential  constituent  of  hemo- 
globin. It  is  often  associated  with  gastric  disturbances,  constipation, 
defective  hygiene,  and  irregular  habits,  and  also  has  been  associated 
with  oral  sepsis,  which  apparently  have  a  casual  relation.  The  skin 
and  mucous  membranes  are  pale  and  have  a  slightly  greenish  tinge.- 
In  recovery  the  number  of  corpuscles  is  first  increased,  then  the 
hemoglobin. 

Leukocytosis. — This  is  not  a  form  of  anemia,  but  a  temporary 
increase  in  the  number  of  multinucleated  leukocytes,  apparently 
derived  from  the  lymphoid  structures  of  the  body  in  response  to 
some  demand  for  leukocytes.  Thus  it  occurs  normally  after  a  full 
meal,  in  the  later  months  of  pregnancy  (13,000)  or  in  the  postpartum 
state  [15,000],  pathologically  after  hemorrhage,  in  acute  fevers,  in 
tuberculosis,  in  sarcomas  and  in  conditions  accompanied  by  suppu- 
ration.^ Its  presence  during  the  course  of  surgical  disease  has  been 
held  to  be  diagnostic  of  pus  formation* — e.  g.,  in  abdominal  surgery 
from  8000  to  40,000  per  cubic  millimeter.  In  general  above  10,000 
is  regarded  as  leukocytosis  20,000  to  50,000  as  hyperleukocytosis. 
(See  Plate,  Fig.  IV.)  In  its  opposite  leukopenia  the  white  cells  may 
be  about  4000  per  cubic  millimeter,  6000  being  about  the  dividing 
fine.     Infectious  diseases  are  usually  accompanied  by  it.^ 

Leukemia. — Leukemia  is  a  disease  characterized  by  a  consider- 
able increase  in  the  number  of  white  corpuscles  of  the  blood,  by  a 

'  Green,  Patholoey  and  Morbid  Anatomy. 

2  Ibid.  '  ^  Ibid. 

*  Cabot,  Boston  Medical  and  Surgical  Journal.      '=  See  works  on  General  Pathology. 


24  DISTURBANCES  OF  THE  VASCULAR  SYSTEM 

diminution  in  the  number  of  the  red  corpuscles,  and  by  enlargement 
of  some  of  the  lymphatic  organs.  The  proportion  of  one  white  to  ten 
red  corpuscles  is  common  (1  to  5  often,  occasionally  1  to  1).  The 
spleen  may  be  hypertrophied  (splenic  leukemia).  The  lymphatic 
glands  may  be  hypertrophied  (lymphatic  leukemia).  In  these  latter 
cases  the  blood  contains  an  excess  of  uninuclear  leukocytes.  It  is  rare 
except  when  combined  with  other  forms.  When  the  marrow  of  bones 
is  hypertrophied  (myelogenic  leukemia)  large  mononuclear  leukocytes 
with  neutrophile  granules  are  found^  (myelocytes)  and  the  lympho- 
cytes and  polymorphonuclear  forms  are  increased.^  The  blood  con- 
tains toxic  substances  generated  by  the  destruction  of  leukocytes, 
xanthin  bodies,  and  acids  (lactic,  acetic).  The  urine  frequently 
contains  an  excess  of  xanthin  bases  and  lactic  acid.  (See  Plate, 
Figs.  VI  and  VII.) 

Pernicious  Anemia. — This  is  a  comparatively  rare  but  generally 
fatal  disease,  characterized  chiefly  by  a  great  fall  in  the  number  of 
red  corpuscles  to  one  million  or  less  per  cubic  millimeter,  those 
remaining  being  altered  in  form  and  size  and  showing  evidences  of 
degeneration.  The  total  hemoglobin  is  reduced,  but  the  relative 
amount  may  be  increased.  Degeneration  is  shown  by  peculiarities 
of  staining.  Normal  red  corpuscles  (normocytes),  nucleated  red 
corpuscles  (megaloblasts),  large  nucleated  red  corpuscles  (giganto- 
blasts),  microcytes,  and  poikilocytes  are  found.  The  blood  platelets 
and  leukocytes  are  somewhat  diminished.^  The  oxygen-carrying 
power  is  markedly  lessened  and  all  tissues  suffer  from  malnutrition. 
The  power  of  coagulation  of  the  blood  is  lessened.  Marked  fatty 
degeneration  of  the  heart  muscles  is  apt  to  occur*  as  well  as  fatty 
changes  in  the  kidneys  and  liver. 

The  causes  are  obscure,  but  gastro-intestinal  disorders,  intestinal 
parasites,  pregnancy  and  lactation,  hemorrhages,  malaria,  syphilis, 
tuberculosis,  and  infections  are  the  chief  causes  supposed  to  produce  it. 

Aplastic  anemia  is  a  severe  type  of  progressive  pernicious  anemia, 
in  which  the  bone-marrow  fails  to  develop  myelocytes  and  erythro- 
blasts  owing  to  lack  of  marrow  cells  (hypoplasia  of  bone-marrow.) 

COAGULATIVE  DISTURBANCES  AND  HEMORRHAGE. 

The  blood  when  drawn  from  the  body  or  in  contact  with  a  wounded 
surface  of  injured  vessel  wall  undergoes  a  process  of  solidification 

'  Ziegler,  General  Pathology. 

2  Stengel,  A  Text-book  of  Pathology. 

'  Green,  Pathology  and  Morbid  Anatomy. 

*  Ibid. 


COAGULATIVE  DISTURBANCES  AND  HEMORRHAGE        25 

called  coagulation.    The  nature  of  the  process  is  in  some  doubt,  but 
it  is  now  thought  that  the  following  reactions  occur  :^ 

Thrombogen  +     Thrombokinase  =     Thromboplastin 

(in  leukocytes  and  platelets.)  (in  platelets  and  tissue.) 

Thromboplastin    +     Antithrombin     =      Prothrombin 
Prothrombin  +     Calcium  salts      =      Thrombin 

Thrombin  +     Fibrinogen  =      Fibrin 

(in  the  plasma.) 

Fibrin  entangling  corpuscles  =     Clot. 

Fibrin  forms  a  network,  in  the  open  spaces  of  which  the  corpuscles 
are  entangled  (Fig.  2).  Occurring  after  an  accident  or  surgery 
opening  bloodvessels,  coagulation  causes  the  cessation  of  hemorrhage 
by  plugging  the  vessels  with  a  thrombus  (or  clot  within  the  living 
vessel).  In  the  case  of  a  ligated  artery  this  extends  to  the  next 
anastomosing  branch.  The  filling  of  vacant  spaces  such  as  abscess 
cavities  or  alveoli  of  teeth  after  extraction,  also  assists,  not  only  in 
checking  hemorrhage,  but  also  acts  as  a  scaffold  for  the  granulation 
tissue,  which  brings  about  regeneration  of  the  part.  The  clot  is  grad- 
ually absorbed  (see  page  56).  In  inflammation  the  lymph  exudate 
may  coagulate  in  the  tissue  spaces,  apparently  an  effort  to  limit  or 
define  the  area  by  blocking  up  the  lymphatics.  Coagulation  may 
occur  in  the  living  vessel,  as  a  thrombus,  or  in  the  interstitial  tissue, 
as  in  inflammation  and  infarction. 

Thrombosis.  —  The  formation  of  thrombi  or  clots  within  the 
living  vessel  may  occur  in  the  heart,  arteries,  veins,  or  capillaries.  If 
the  blood  stream  be  somewhat  retarded,  an  increased  number  of 
white  corpuscles  and  blood  platelets  occupy  the  peripheral  zone  and 
adhere  to  the  vessel  wall.  If  the  vessel  wall  be  injured,  the  blood 
platelets  become  attached  to  it.  With  these  platelets  the  white 
corpuscles  and  sometimes  the  red  become  deposited.  Fibrin  forms 
and  the  corpuscles  are  included.  The  thrombus  is  red  when  red 
corpuscles  are  included  in  it;  white  when  only  white  corpuscles  are 
present.  The  causes  of  thrombosis  are  these:  (1)  a  retardation  of 
the  blood  current  at  some  point  from  some  cause;  (2)  local  changes 
in  the  walls  of  the  vessels  and  (3)  probably  pathological  changes  in 
the  blood." 

Older  thrombi  are  firmer  than  those  recently  formed.  Thrombi 
are  also  formed  in  the  capillaries,  a  circumstance  which  favors  the 
spontaneous  cessation  of  hemorrhage.^  They  may  form  in  the  vessels 
in  inflammation.'*  Remaining  in  the  situations  in  which  they  were 
formed,  they  either  undergo  simple  or  puriform  softening  or  are 

^  Howell,  Text-book  of  Physiology. 

2  Ziegler,  General  Pathology. 

5  See  above.  *  See  page  38. 


26 


DISTURBANCES  OF  THE   VASCULAR  SYSTEM 


calcified,  or  are  resorbed  and  replaced  by  connective  tissue.     (See 
Regeneration.)     The  calcified  varieties  are  called  phleboliths  in  the 

veins;    arterioliths    in   the    arte- 
FiG.  2  ries.     The  effect  of   a  thrombus 

is  to  obstruct  circulation  in  the 
degree  in  which  it  closes  the 
lumen  of  the   vessel.     Thus   in 


Fig.  3 


Fibrin  filaments  and  blood  tablets. 
A,  network  of  fibrin,  shown  after 
washing  away  the  corpuscles  from  a 
preparation  of  blood  that  has  been 
allowed  to  clot;  many  of  the  fila- 
ments radiate  from  small  clumps  of 
blood  tablets ;  B  (from  Osier) ,  blood 
corpuscles  and  elementary  particles 
or  blood  tablets  within  a  small  vein. 


Fig.  4 


A  thrombus  in  the  saphenous  vein, 
showing  the  projection  of  the  conical 
end  of  the  thrombus  into  the  femoral 
vessel:  S,  saphenous  vein;  T,  throm- 
bus; C,  conical  end  projecting  into 
femoral  vein.  At  v,  v,  opposite  the 
valves,  the  thrombus  is  softened. 
(Virchow.) 


Diagram  to  show  phenomena  of 
venous  thrombosis:  v,  v,  valves  of  veins, 
a,  b,  primary  thrombus  (white) ;  c,  d; 
e,  f,  g,  secondary  white  thrombi  con- 
nected with  primary  white  thrombus 
by  various  red  thrombi;  h,  piece  of  white 
thrombus  becoming  detached  by  blood 
current.  If  septic  this  would  be  a  possible 
cause  of  septic  infarction  (or  pyemic  meta- 
stasis).     (Green,  modified  from  Thoma.) 


(1)  trauma  it  plugs  it  completely,  obstructing  hemorrhage;  (2) 
occurring  in  an  artery  (not  by  trauma)  it  tends  to  cause  ischemia  of 
a  part  supplied  by  it  and  may  cause  necrosis  (dry  gangrene)  by  lack 


COAGULATIVE  DISTURBANCES  AND  HEMORRHAGE 


27 


of  food  supply  (nutrition) ;  (3)  in  a  vein  it  tends  to  prevent  return 
of  blood  to  the  heart  (venous  hj-peremia)  and  if  this  is  partial,  de- 
generation is  produced,  if  total,  necrosis  (moist  gangrene) .  A  clot  in 
a  vessel  may  extend  a  great  distance  (Figs.  3  and  4). 

Embolism. — Portions  of  the  softened  varieties  of  thrombi  may 
become  detached  and  float  about  in  the  blood;  these  are  called 
emboli.  Other  foreign  substances  may  act  as  emboli — e.  g.,  air  or 
fat  globules.  In  important  parts  it  may  cause  local  anemia,  paralysis, 
or  slow  or  rapid  death  (Fig.  5). 


Fig. 


Fig.  6 


Embolus  impacted  at  the  bifurcation 
of  a  branch  of  the  pulmonary  artery, 
showing  the  formation  of  thrombi  be- 
hind and  in  front  of  it,  and  the  exten- 
sion of  these  as  far  as  the  entrance  of  the 
next  collateral  vessels:  E,  embolus;  t, 
t' ,  secondary  thrombi.      (Virchow.) 


Diagram  of  a  hemorrhagic  infarct: 
a,  artery  obliterated  by  an  embolus  (e) ; 
V,  vein  filled  with  a  secondary  throm- 
bus {ih);  1,  centre  of  infarct  which  is 
becoming  disintegrated;  2,  area  of 
extravasation;  3,  area  of  collateral  hy- 
peremia. If  caused  by  an  infective 
embolus  an  abscess  may  result.  (O. 
Weber.) 


If  the  thrombus  be  septic,  as  in  the  case  of  puriform  softening,  the 
emboli  may  lodge  in  small  vessels  and  cause  secondary  septic  disease 
processes,  as,  for  example,  in  the  cases  of  pyemia  accompanied  by 
infarctions  in  which  multiple  metastatic  (or  miliary)  abscesses  are 
formed,  each  causing  local  injury  and  acting  as  a  fresh  focus  of  infec- 
tion as  well  (see  page  47  and  below). 

Infarction. — When  an  embolus  occludes  a  terminal  artery,  that 
is,  an  artery  whose  branches  spread  like  those  of  a  tree  without 
anastomosis,  the  part  first  becomes  ischemic,  but  soon  the  backward 
pressure  from  the  vein  upon  the  blood  in  the  capillaries  causes  an 
extravasation  of  blood  into  the  interstitial  tissue  of  the  wedge-shaped 
area,  forming  what  is  called  a  hemorrhagic  infarct.     A  clot  forms 


28  DISTURBANCES  OF  THE  VASCULAR  SYSTEM 

degeneration  of  the  clot  occurs,  and  if  aseptic  it  is  absorbed  and 
replaced  by  connective  tissue  (see  Regeneration);  if  caused  by  a 
septic  embolus,  it  may  be  involved  in  the  resulting  septic  process— 
e.  g.,  in  pyemic  metastatic  abscess.  Infarction  has  been  held  by 
Black  to  occur  in  the  dental  pulp,  but  he  has  not  proved  the  case  as 
he  distinctly  describes  infarction  as  the  stasis  of  venous  h\^eremia, 
quite  a  different  condition. ^  A  demonstration  has  been  made  by 
Hopewell-Smith  of  a  pulp  disease  which  might  be  infarction,  yet  hav- 
ing from  the  description  certain  characteristics  of  venous  hyperemia. 
(See  Infarction  of  Dental  Pulp.)     (Fig.  6.) 

Hemorrhage. — By  hemorrhage  is  meant  the  escape  of  blood  from 
the  vessels.  It  may  be  arterial,  venous,  or  capillary.  If  the  vessel 
is  ruptured,  it  is  hemorrhage  by  rhexis.  If  it  occurs  by  diapedesis, 
as  in  infarction  (into  the  tissue  spaces\,  it  is  hemorrhage  by  diapedesis. 
The  diapedesis  occurs  through  the  capillary  wall  rather  than  the 
stoma ta;  pressure  is  the  cause.  Hemorrhage  usually  ceases  spon- 
taneously through  thrombosis,  as  previously  described. 

If  hemorrhage  occurs  into  the  tissues  it  receives  the  following 
designations,  the  escape  itself  being  called  an  effusion  or  extravasation: 

Ecchymosis,  an  effusion  of  moderate  extent  into  tissue  beneath  a 
surface,  as  into  subcutaneous  tissue. 

Petechia  the  same,  but  small  and  circumscribed. 

Suffusio7i  the  same  when  an  extensive  area  is  involved.  The  term 
also  covers  the  staining  of  bone  or  dentin  by  hemoglobin,  e.  g.,  suffusion 
of  dentin  of  the  crown  and  root  in  venous  h\'peremia  of  the  pulp. 

Infarction,  when  the  area  involved  is  that  supplied  by  terminal 
and  non-anastomosing  arteries  as  above  described. 

Hemorrhage  involves  an  injury  to  vessels  by  traumatism,  or 
disease  rendering  thera  incapable  of  retaining  the  blood,  or  by 
increased  internal  pressure,  as  in  violent  exertion,  or  in  congestion 
of  local  vessels,  as  in  venous  hyperemia,  or  as  the  result  of  diminished 
external  atmospheric  pressure,  as  in  high  altitudes.  The  extravasated 
blood  may  be  absorbed  or  deposited  in  the  tissues,  as  in  a  bruise; 
or  excite  inflammation  or  cyst  formation  (extravasation  cyst) .  Acute 
hemorrhages  or  repeated  extravasations  lead  to  anemia  (which  see). 
The  extravasated  corpuscles  may  be  disintegrated  and  the  hemo- 
globin broken  up  into  varying  compounds  haA'ing  various  colors.  This 
is  hemaiogenous  pigmentary  infiltration  and  may  be  seen  in  a  bruise. 
The  colors  are  often  permanently  deposited.  The  color  changes  may 
occur  in  some  degree  in  teeth  suft'used  through  venous  h\^eremia 
or  the  hemoglobin  may  be  modified  by  pulp  putrefaction  (see  Pulp 

»  Special  Dental  Pathology,  p.  257  (Ed.  1915). 


COAGULATIVE  DISTURBANCES  AND  HEMORRHAGE         29 

Putrefaction  and  Bleaching  of  Teeth).    As  seen  in  a  bruise  the  extra- 
vasations produce  the  following  pigmentary  infiltrations: 

(a)  Hemoglobin,  dark  red. 

(b)  Hemin,  reddish-brown  or  bluish-black. 

(c)  ]\Iethemoglobin,  brownish-red. 

(d)  Hematin,  dark-brown  or  bluish-black. 

(e)  Hematoidin,  orange  or  reddish-brown  (light  pea  green  (Jakob)). 
(/)  Hemosiderin,  yellowish  or  brownish. 

Hemorrhagic  Diathesis. — This  is  a  condition,  largely  hereditary, 
in  w^hich  coagulation  does  not  close  wounds  readily,  and  ordinarily 
trivial  wounds  may,  in  spite  of  surgical  aid,  induce  death  by  hemor- 
rhage. Hereditary  hemorrhagic  diatheses  (hemophilia)  is  usually 
transmitted  through  the  female  to  the  male  descendants — i.  e.,  from 
grandfather  to  grandson  through  the  grandfather's  daughter — and 
seven  or  more  generations  of  hemophilics  have  been  recorded.^ 
Males  suffer  more  than  females  in  the  ratio  of  about  11  to  1. 

In  a  family  of  207  members,  in  four  generations,  37  were  hemo- 
philics, all  of  the  male  sex;  almost  half  died  from  hemorrhages, 
usually  in  infancy,  while  in  the  living  the  tendency  to  bleed  lessened 
as  they  grew  older.- 

According  to  Legg,^  "  It  is  of  three  degrees  of  severity : 

"1.  Characterized  by  external  and  internal  bleedings  of  every 
kind,  and  by  joint  affections. 

"2.  By  spontaneous  hemorrhages  from  mucous  membranes,  but 
no  traumatic  bleeding  or  ecchymoses,  and  no  joint  affections. 

"3.  A  tendency  simply  to  ecchymoses.  The  first  seen  most 
frequently  in  men,  the  second  in  women;  the  third  may  appear 
in  either  sex." 

The  joint  affections  are  due  to  hemorrhage,  and  simulate  rheumatic 
affections.  Hemophilics  are  apt  to  be  thin-skinned,  neurasthenic, 
and  liable  to  sudden  flushings  and  vasomotor  disturbances.^  Blondes 
suffer  more  than  brunettes.^ 

The  injured  part  may  bleed  from  the  first,  or  a  normal  clot  may 
form  and  secondary  hemorrhage  or  capillary  oozing  occur.  Death 
may  rapidly  occur,  or  the  patient  bleed  to  fainting  or  until  almost 
dead,  and  hemorrhage  then  cease.  This  may  require  any  period, 
even  w^eeks.    One  case  is  said  to  have  continued  for  a  year.^ 

The  pathology  of  the  condition  is  uncertain.  Fillebrown^  reports 
a  fatal  case  in  which  the  arteries  were  excessively  thin.    Porter^  points 

1  Porter,  International  Dental  Journal,  1900. 

2  Losser,  International  Journal  of  Surgery. 

3  Musser,  Medical  Diagnosis.  ^  Thompson,  Practical  Medicine. 

^  Scott,  Dental  Cosmos,  1912,  p.  60.  ^  International  Dental  Journal,  1900. 

'  Porter,  Loc.  cit. 


30  DISTURBANCES  OF  THE  VASCULAR  SYSTEM 

out  that  the  blood  may  clot  in  the  receptacle,  yet  not  in  the  small 
vessels  of  the  wound,  and  infers  that  some  hereditary  deficiency  exists 
which  interferes  with  the  action  of  the  vasoconstrictors. 

Hemophilics  usually  manifest  a  history  of  bleeding  before  puberty, 
and  hemophilic  infants  have  died  from  hemorrhage  due  to  gum- 
lancing,  circumcision,  etc.  Certain  surgical  cases  in  which  secondary 
hemorrhages  have  been  due  to  the  action  of  the  continuous  use  of 
acetanilid  have  been  reported. 

Treatment  of  Hemorrhage. — Hemorrhages  in  general  are  controlled 
or  prevented  upon  four  local  and  three  systemic  principles  which  may 
be  combined  for  more  rapid  effect. 

1.  ]\Iechanically  obstructing  the  flow  of  blood  by  ligatures,  hemo- 
static forceps,  compression  of  the  artery  leading  to  the  part,  pressure 
of  tampons  upon  the  open  bleeding  vessels  which  may  be  reinforced 
by  compresses  and  in  case  of  the  jaws  forcible  closure  of  the  teeth 
upon  the  compress  by  a  Barton  or  other  bandage.  Elevation  and 
rest  of  the  part  counteract  gravity  and  muscular  propulsion.  In  a 
severe  hemorrhage  upon  the  palate,  as  after  lancing,  finger  pressure 
may  be  used  or  a  \'iilcanite  or  even  a  modelling  compound  plate, 
made  to  produce  pressure.^  In  alveolar  hemorrhage  clots  about 
which  hemorrhagic  leakage  occurs,  should  be  removed  before  packing 
the  alveolus. 

2.  Injury  of  the  white  corpuscles.  This  liberates  the  ferments 
necessary  for  coagulation.  It  has  been  noted  that  lacerated  wounds 
bleed  less  than  smoothly  cut  ones.  An  implantation  may  be  done 
with  rough  reamers  almost  bloodlessly  as  compared  with  an  extrac- 
tion. The  mechanical  treatment  probably  acts  in  some  degree  upon 
this  principle  aside  from  obstructing  the  flow  of  blood.  The  torsion 
of  a  tooth-pulp  before  removal  causes  the  same  effect.  Actual  cau- 
terization does  the  same.  Torsion  of  an  artery  in  a  wound  acts  upon 
the  same  principle. 

3.  Local  vasoconstriction  is  attained  by  the  use  of  astringents  in 
case  of  small  injuries,  as  upon  the  gum,  or  combined  with  the  tampons, 
as  in  a  tooth  alveolus.  Tannic  acid,  alum  (both  powdered),  Monsel's 
solution,  ethereal  pyrozone,  adrenalin  or  suprarenin  solution  (in  case 
of  hemophilia,  potassium  permanganate  made  into  a  paste  with 
vaseline  is  recommended)  are  examples  of  this  principle.  It  is  also 
exemplified  by  the  effect  of  cold  applications  and  by  the  blanching 
effect  of  adrenalin  or  suprarenin  either  in  the  hypodermic  injection 
(with  cocain  or  novocain)  or  superficially  applied  for  prevention  of 
hemorrhage,  as  in  nasal  surgery,  or  for  reduction  of  conjunctivitis, 

1  Joly:    Dftnta)  Cosmos,  1909,  p.  488. 


COAGULATIVE  DISTURBANCES  AND  HEMORRHAGE        31 

4.  Coagulation  of  the  albumin  of  the  blood.  This  may  be  produced 
by  drugs  applied  locally,  many  of  the  astringents  having  this  effect, 
as  for  example,  deliquesced  chlorid  of  zinc,  strong  silver  nitrate 
solutions,  alum  or  tannic  acid  in  powder  or  solution.  The  actual 
cautery  also  coagulates  by  heat  as  well  as  injury  of  the  leukocytes. 
Hall  suggests  having  ready  absorbent  cotton  first  wet  with  a  saturated 
solution  of  alum  in  distilled  water  and  then  dried. ^ 

The  three  systemic  principles  are: 

1.  General  vasoconstriction  to  be  used  in  capillary  hemorrhage 
(and  avoided  in  those  from  cut  arteries  as  in  these  hemorrhage 
would  be  increased).  Probably  this  increases  friction  thus  causing 
injury  of  leukocytes.  For  this  purpose  there  are  employed,  dilute 
sulphuric  acid  (20  to  30  minims  pro  re  nata),  oil  of  Erigeron  cana- 
densis, 20  minims  on  sugar  pro  re  nata,  ergot  (of  the  wine,  a  tea- 
spoonful  each  two  hours,  of  the  fluidextract  one-half  teaspo^nful 
each  two  hours)  suprarenal  extract  (as  adrenalin  1  to  1000)  intra- 
venously drop  by  drop  up  to  10  minims  (Stevens)  or  grains  10 
by  mouth  in  the  form  of  dried  extract.  Tannic  acid  or  gallic  acid, 
10  grs.  in  pill  pro  re  nata.  Aqueous  extract  of  Hamamelis,  teaspoon- 
ful  pro  re  nata,  or  the  fluidextract,  20  minims  pro  re  nata.  The 
follow^ing  is  a  practical  prescription  having  marked  vasoconstricting 
action: 

'Bf — Acidi  gallici gr.  xxxvi 

Pulveris  digitalis gr.  xij 

Ergotini gr.  x 

Pulveris  opii gr.  vj 

M.  et  pone  in  capsulas,  No.  xij  (M.  R.  Taylor  attributes  to  Hare). 

2.  Increasing  the  coagulability  of  the  blood.  This  treatment  is 
based  upon  supplying  the  blood  with  calcium  salts  or  some  constit- 
uent necessary  to  the  coagulation  process.  In  actual  hemorrhage 
calcium  chlorid  in  a  massive  dose  of  75  grs.  in  solution  in  water  by 
mouth  (or  clyster  if  necessary),  or  20  grs.  by  mouth  followed  by  5  grs. 
each  hour  up  to  5  or  6  doses  (Hare).  Strontium  lactate,  15  grs. 
pro  re  nata,~  calcium  lactate  first  dose  20  grs.,  5  grs.  each  hour  and 
increasing  to  20  grs.,  sodium  sulphate  grs.  iss  every  two  hours.^ 

Lederer  has  suggested  the  injestion  of  as  many  raw  eggs  as  the 
patient  can  bear  during  a  period  of  thirty-six  hours  before  operation.^ 
P.  Emile  Weil  has  suggested  the  injection  of  20  c.c.  of  fresh  human, 
horse,  or  rabbit  serum  before  operation,  for  the  prevention  of  hemor- 

1  Dental  Cosmos,  1916,  p. .949. 

2  Scott:  New  Jersey  Dental  Journal,  October,  1913. 

3  Reverdin:  Dental  Cosmos,  February,  19Q4,  p,  162. 

4  Dental  Digest,  1914,  p.  263, 


32  DISTURBANCES  OF  THE  VASCULAR  SYSTEM 

,        ;„  liPmoDhilics  or  every  three  months  as  a  curative  measure.' 
rhage  in  hemopnmcs.oi  „t,poked  a  pers  stent,  dangerous, 

Beam  and  Dolmage^  successfully  ^^^<^^<'^  "  P      ;       intravenously 
eleven-day  hemorrhage  m  a  h^ophihc  b,   »  ect    g 

120  c.c.  of  fresh  horse  -»-■  ^f  ^^'s    tt're  ort'  tSe  use  of 
'aJ^rof  —  =h;ChyyLc  syrln£as  lmme« 

'  rB^t^wee  blacks.    The  back  was  selected  as  the  site  of 
• -In-'^o  Z.  -an  .rum  he  -^^^  ntSS 

:;l\l)Brewste.shemostatie.(2U^^^^^^^^^ 

cutaneous  V  with  success.     This  preparation  is  stated     to  contam 
protlmbin  and  anti-antithrombin,  the  antithrombin,  which  would 
V  ttTe  Se  action  of  the  prothrombin,  having  been  ehmmated    and 
"tTla  rboth  a  local  hemostatic  action  when  applied  on  gau  e 
and    o  increase  the  coagulability  of  the  blood  when  subcutaneous  y 
dmhltered  and  not  to  P-d-e  dangerous  po.^^^^^^^^^^^^ 
thrombosis  and  anaphylactic  shock  or  toxic  effect.       i he  average 
dose  is  To  2  mils,  repeated  every  four  to  six  hours  until  control 
of  hemcH^age  is  obtained.    It  is  furnished  in  sterile  bulbs     Being 
'oveda^^  a  product  of  a  reliable  house  and  readily  available  it  shou  d 
Nearly  trial  in  all  severe  hemorrhages.    It  has  been  used  wi  h 
success  as  a  prophylactic,  preventing  hemorrhage  m  bleeders  with 
history  of  hemorrhage  at  previous  operations  .   i  i     •  j 

In  known  hemophilics,  with  operation  unavoidable  calcium  chlorid, 
gr.  iij  ter  in  die  for  not  more  than  four  days,  ^^ybe  given  and  the 
operation  performed.  After  four  days  the  coagulability  of  the  blood 
is  decreased  (Hare).  In  the  writer's  hands  this  has  allowed  almost 
a  bloodless  extraction  in  a  hemophilic.  It  disturbs  the  stomach 
somewhat.  Doses  of  ergot  for  a  less  period  might  be  used  previous 
to  operation.  The  danger  of  ergot  gangrene  (from  intense  vaso- 
constriction) should  always  be  borne  in  mmd. 

3  Mechanical  test  of  mind  and  body  is  necessary  m  serious  cases 
of  hemorrhage  to  avoid  muscular  propulsion,  rupture  of  ligated 
vessels,  or  disturbance  of  bandages.    The  use  of  tincture  of  aconite  m 

1  Dental  Cosmos,  1908,  p.  346.  „ 

2  Dental  Items  of  Interest,  March,  1-915.  =  Ibid.,  January,  1912. 
4  Private  Communication. 


LOCAL  DISTURBANCES  OF  THE  CIRCULATION 


33 


small  repeated  doses  slows  the  heart  action.  Food  should  be  withheld 
from  hemophilics  and  the  hmiger  relieved  with  small  doses  of  opium 
and  thirst  by  iced  water  in  small  quantities  or  bits  of  cracked  ice. 
Individuals  known  to  be  hemophilics  should  live  a  hygienic  life, 
avoid  all  injuries  however  slight,  in  the  hope  of  an  eventual  out- 
growing of  the  condition.  The  acute  anemia  induced  by  prolonged 
hemorrhage  requires  treatment  by  hematics,  although  in  healthy 
individuals  the  blood  lost  by  a  moderate  hemorrhage  is  rapidly 
replaced  after  feeding  with  nutritious  foods. 

LOCAL  DISTURBANCES  OF  THE  CIRCULATION. 

The  amount  of  blood  in  a  part  may  be  increased  or  diminished. 
The  types  of  local  disturbance  differ  as  to  causes,  phenomena  and 
effects,  and  as  to  the  indicated  treatment  for  each.    In  health  the 


Fig.  7 


Ramification  of  nerves  and  termination  in  the  muscular  coat  of  a  small  artery 
of  the  frog.     (Arnold,  Kirke's  Physiology). 

bloodvessels  are  maintained  at  a  proper  caliber  through  the  action 
of  the  vasomotor  nerves,  disturbances  of  which  permit  dilatation  of 
the  arteries,  as  is  generally  the  case  in  arterial  h^^eremia.  On  the 
other  hand,  simple  mechanical  retention  of  blood  may  cause  dilata- 
tion or,  better,  expansion  of  the  veins,  as  in  venous  hyperemia. 

Ischemia. — This  is  local  anemia  due  to  (1)  obstruction  of  an 
artery  leading  to  a  part  or  pressure  upon  the  part  causing  emptyness 
of  capillaries;  (2)  substitution  of  the  blood  by  fluid  as  in  h^-podermic 
injections  (enhanced  if  vasoconstringents  as  suprarenin  are  con- 
joined). The  condition  may  be  but  temporary.  If  continued  the 
effects  are  those  due  to  lack  of  nutrition,  i.  e.,  atrophy,  degeneration, 
necrosis. 
3 


34  DISTURBANCES  OF  THE  VASCULAR  SYSTEM 

Arterial  Hyperemia. — Iiihibition  of  vasoconstrictor  nerve  fibers  or 
stimulation  of  vasodilators  causes  a  dilatation  of  arterial  vessels. 
The  muscular  coat  loses  its  tone  and  relaxes.  The  blood,  there- 
fore, increases  in  volume.  If  the  irritation  does  not  carry  the  part 
beyond  this  state  and  into  inflammation  the  condition  is  a  simple 
excess  of  blood  in  the  arteries  and  arterial  capillaries  with  the  motion 
increased  and  denominated  arterial  hj'peremia. 

Cause. — It  is  probable  that  the  cause  of  vasodilatation  is  a  vaso- 
motor impulse  excited  in  response  to  a  sensory  impulse  sent  to  the 
brain  from  the  irritated  part.  The  specific  irritants  are  many. 
(See  Arterial  Hyperemia  of  Pulp.) 

Results. — Obviously  the  good  arterial  blood  in  excess  produces 
excess  nutrition  with  consequent  excess  of  all  functions.  The  part 
is  reddened,  more  capable  of  functions,  the  arterial  walls  overnour- 
ished  by  blood  (via  vasavasorum)  and  may  be  thickened  in  continued 
cases ;  enlargements  of  parts  occur  (hypertrophy  by  cell  growth  and 
reproduction)  in  continued  cases.  The  temperature  is  increased, 
owing  to  increased  chemical  change  (oxidation,  etc.),  and  the  part 
is  more  sensitive  to  all  external  impressions  owing  to  the  increased 
function  of  the  nerves  (resulting  in  hyperesthesia).  In  the  hard 
tissues  increased  depositions  occur,  the  tissue  becoming  more  dense 
(osteosclerosis — tubular  calcification  in  dentin,  etc.),  or  added  to,  as 
in  secondary  dentin,  hypercementosis  of  roots,  exostosis,  etc.  See  Index. 

The  above  is  true  of  the  milder,  continued  grades;  in  more  marked 
cases  some  pain  of  throbbing  character  or  disturbance  of  nutrition 
may  occur.  It  is  to  be  remembered  that  being  due  to  irritation  it 
may  involve  in  some  cases  a  degree  of  mild  inflammation  and  in  the 
dental  pulp  a  venous  hyperemia  of  greater  or  less  degree.  Its  effects 
are,  however,  often  evidence  of  its  long-continued  action  either  as  a 
pure  condition  or  as  an  association  with  inflammation  as  one  of  its 
zones  (the  outer).    (See  Pulp  Diseases  and  page  40.) 

Hyperemia  as  a  Resistance  to  Infection. — According  to  Biers  and 
others  the  induction  of  hyperemia  in  an  infected  part  increases  the 
opsonic  power  of  the  excess  blood,  and  therefore  is  antagonistic  to 
infection.  No  doubt  this  is  the  natural  process  in  inflammation.  It 
has  been  occasionally  noticed  that  stimulation,  as  in  the  use  of  a 
capsicum  plaster  in  acute  apical  abscess,  has  produced  resolution. 
Usually  confined  abscesses  are  enlarged  and  not  cured  by  such 
stimulation. 

Venous  Hyperemia  (Mechanical  or  Passive). — Venous  hyperemia 
is  a  collection  of  blood  in  the  veins  due  to 

1,  Prevention  of  its  passage  through  the  vein  on  the  way  to  the 
heart  by  some  obstruction  (pressure  on  vein,  thrombus  in  vein,  etc.). 


LOCAL  DISTURBANCES  OF  THE  CIRCULATION 


35 


2.  Lack  of  propulsive  force  usually  in  the  heart  whereby  the  arte- 
rial column  of  blood  cannot  force  a  proper  circulation  and  the  blood 
tends  to  collect  in  the  more  dependent  parts.  This  may  involve 
diminished  cardiac  power,  valvular  disease,  arterial  rigidity  or 
obstruction  or  valvular  incompetency  of  veins. 

The  second  cause  has  onl}'  a  remote  dental  interest.  The  first  is 
involved  in  venous  pulp  h\'peremia  and  is  the  cause  of  the  second 
stage  of  inflammation.  It  is  also  a  means  of  therapeutics  invoked 
when  it  is  desired  to  induce  some  forms  of  Bier's  hyperemia,  as  for 
example,  in  the  use  of  the  stasis  bandage  about  the  neck  in  local  anes- 
thesia, the  object  here  being  to  slow  the  circulation  away  from  a  part 
to  be  injected  by  retaining  the  blood  in  the  head. 

Pathology. — The  veins  are  dilated,  the  current  is  slowed,  and  the 
intravenous  pressure  is  increased,  in  consequence  of  which  watery 
(serous)  exudations  occur  in  the 
parts  about  them  (edema).  For 
the  same  reason  in  marked  cases 
diapedesis  of  red  corpuscles  may 
occur  (hemorrhage  by  diapedesis) , 
and  their  hemoglobin  may  be  dis- 
solved out.  The  blood  in  the  parts 
not  being  sufficiently  changed, 
and  in  some  cases  in  a  state  of 
stasis,  there  is  a  lessened  food 
supply  and  waste  removal,  and 
cell  nutrition  suffers  accordingly. 
Vital  processes  are  lessened,  secre- 
tion is  diminished,  there  is  less  oxi- 
dation, and  hence  less  heat  is  pro- 
duced and  less  work  is  done.  Fatty 

degeneration  or  atrophy  occurs  in  partial  cases  and  in  more  complete 
cases  necrosis  may  occur,  as  stasis  prevents  the  access  of  food  supply 
(arterial  blood).  Long-continued  venous  h\^eremia  with  great  intra- 
venous pressm-e  may  produce  dropsies.  If  the  walls  of  the  veins  are 
weak  and  are  permanently  distended  or  thicken  under  pressm-e  and 
become  tortuous,  the  condition  is  called  varicosity  of  the  veins  (vari- 
cose veins).  The  exudate  of  venous  hyperemia  differs  markedly 
from  that  of  inflammation  (Fig.  8).^ 

Htpekemic  Exudate.  Inflammatoht  Exudate. 

Poor  in  albumin.  Rich  in  albumin. 

Rarely  coagulates  in  the  tissue.  Usually  coagulates  in  the  tissue. 

Contains  few  cells.  Contains  numerous  cells. 

Low  specific  gravity.  High  specific  gravity. 

Contains  no  peptone.  Contains  peptone  (product  of  cell 

disintegration) . 
1  Park's  Surgery.  / 


Venous  hyperemia  of  the  Hver.  Two 
capillaries  near  central  hepatic  vein, 
showing  the  thickening  of  the  walls  and 
the  accumulation  of  red  blood  corpuscles 
within  them.      X  500. (Green.) 


36  DISTURBANCES  OF  THE   VASCULAR  SYSTEM 

This  is  probably  due  to  an  increased  permeability  in  the  vessel  wall 
in  inflammation  permitting  the  albumin  of  the  blood  to  pass  through 
and  to  chemical  changes. 

INFLAMMATION. 

Inflammation  may  be  defined  as  a  series  of  hyperemic  changes 
expressive  of  the  reaction  of  living  tissue  to  irritation,  and  character- 
ized chiefly  by  an  excessive  emigration  of  leukocytes  and  exudation 
of  coagulable  lymph  from  the  bloodvessels. 

Etiology. — Any  irritant  or  injury  capable  of  producing  a  lesion  of 
the  bloodvessel  wall  not  involving  its  immediate  death  can  produce 
inflammation.  In  case  direct  death  is  produced,  the  inflammation, 
if  any,  occurs  in  the  tissue  contiguous  to  the  dead  part. 

The  causes  of  inflammation  may  be  divided  first  into  non-septic 
and  septic  or  infective.  The  non-septic  causes  may  be  extrinsic  or 
intnnsic.  The  extrinsic  non-septic  causes  are:  (1)  Physical  irritants, 
such  as  violence,  mechanical  irritation,  pressure  or  traumatism, 
excessive  heat  or  cold,  and  electrolytic  action.  (2)  Chemical  irri- 
tants— e.  g.,  the  action  of  acids,  caustics,  etc.  (3)  Nervous  or  vital 
irritants — e.  g.,  rubefacients,  epispastics,  arsenic,  etc.  These  act 
only  on  living  tissue  through  the  medium  of  the  nerves. 

An  intrinsic  non-septic  cause  may  produce  inflammation — e.  g., 
urates  in  tissue,  mechanical  strains  upon  tissue,  temporary  lack  of 
blood  in  a  vessel  or  central  nervous  disturbance,  as  in  herpes  from 
locomotor  ataxia. 

Non-septic  causes,  as  a  rule,  produce  only  such  mild  inflammatory 
phenomena  as  are  concerned  in  circumvallation  of  an  irritant, 
absorption  of  it,  and  in  repair  or  production  of  new  tissue.  No 
pus  is  produced  unless  pyogenic  bacteria  gain  ingress.  This  class 
of  inflammation  is  termed  simple  ivflammation.  (For  further  explana- 
tion see  Non-septic  Pericementitis.) 

Septic  or  Infective  Causes. — These  are  fungi  or  their  products, 
and  the  classes  of  inflammations  produced  are  much  more  severe, 
continuous,  and  destructive  in  their  nature,  and  are  termed  infective 
inflavimations. 

Pathology  of  Simple  Inflammation. — If  to  the  web  of  a  frog's  foot 
tincture  of  capsicum  be  applied,  or  if  its  mesentery  be  exposed  to  the 
air,  and  either  be  examined  under  the  microscope  while  the  animal  is 
living,  it  is  noted  that  after  a  possible  short  period  of  contraction  of 
the  arterioles  dilatation  of  arteries  at  once  begins  and  is  gradually 
followed  by  dilatation  of  the  veins  and  capillaries.  This  continues 
to  steadily  increase  for  about  twelve  hours.    During  the  first  hour 


INFLAMMATION 


37 


of  this  period  the  blood  current  is  accelerated  and  the  first  stage 
of  an  inflammation  is  thus  an  arterial  hyperemia.  Following  this 
acceleration  the  blood  flow  is  increasingly  retarded.  The  retardation 
is  due  to  the  action  of  the  leukocytes,  large  numbers  of  the  mono- 
nuclear and  polymorphonuclear  forms  of  which  fall  out  of  the  central 
blood  stream  into  the  periaxial  stream  and  collect  along  the  walls  of 
the  small  veins  (Fig.  9,  h).  Several  layers  of  leukocytes  may  thus 
form.  Probably  some  peculiar  attraction  exists  between  the  leuko- 
cytes and  the  wall  of  the  vessel,  or  a  positive  chemotaxis  exists  as  in 
infective  inflammation. 

Fig.  9 


Small  vein  in  mesentery  of  dog,  after  exposure  for  half  an  hour  and  irrigation  with 
salt  solution :  a,  red  corpuscles ;  6,  leukocytes  adhering  to  wall  of  vein;  c,  red  corpuscles; 
d,  leukocytes  which  have  escaped  from  vessel;  e,  leukocyte  in  act  of  escaping;  /, 
fibrous  tissue.      X  340.     Modified  from  Thoma.     (Green.) 


This  massing  of  leukocytes  compels  the  red  corpuscles  to  the 
center  of  the  stream  (Fig.  9,  a),  and  their  passage  is  mechanically 
interfered  with;  thus  the  further  dilatation  of  the  vessel  becomes 
a  process  of  venous  hyperemia.  The  vessels  are  increased  in  size 
and  length  and  become  more  tortuous.    Pulsation  is  noted. 

Coincident  with  retardation  of  the  blood  flow,  the  leukocytes  are 
seen  to  work  their  way  by  an  ameboid  movement  through  the  walls 
of  the  veins  and  to  some  extent  of  the  capillaries  into  the  perivascular 
spaces — -i.  e.,  into  the  adjoining  tissue — in  which  they  may  move  far 
from  their  point  of  escape  and  mass  about  the  irritant  if  one  be 
present.    This  process  is  called  emigration  (Fig.  9,  e).    At  the  same 


38  DISTURBANCES  OF  THE   VASCULAR  SYSTEM 

time  a  fluid  rich  in  albumin,  and  thus  capable  of  coagulation,  escapes 
by  the  same  route  into  the  tissue  (Fig.  10).  This  is  called  exudation. 
Some  red  corpuscles  also  escape  through  the  walls  (diapedesis) 
(Fig.  9,  c).  While  inflammation  involves  an  arterial  hyperemia 
as  its  first  stage  and  a  venous  h}T)eremia  as  its  second  stage, 
these  two  conditions  are  not  necessarily  inflammation,  and  may 
exist  as  entirely  distinct  conditions  when  produced  by  causes  not 
leading  to  inflammation;  also,  it  must  be  remembered  that  the  results 
of  venous  hyperemia  or  infarction,  e.  g.,  extravasation,  may  lead 
to  a  subsequent  inflammation.  This  does  not  make  them  identical. 
As  the  venous  hyperemia  of  the  inflammation  increases,  the  flow 
of  red  corpuscles  in  the  veins  is  increasingly  retarded  until  stopped, 
when  a  to-and-fro  motion  (oscillation)  begins.  Finally  all  motion 
ceases,  emigration  ceases,  and  stasis  is  complete.     This  blood  may 

remain  fluid  in  the  vessel  for  several  days 

Fig.  10  {i.  e.,  without  coagulation),  and  if  the 

blood  flow  be  reestablished  the  separate 

red  corpuscles  are  seen  one  by  one  to  roll 

away  from  the  general  mass  until  all  are 

Y''^  -    ^     ,  ^  ^      in  movement  and  stasis  ceases.    (Thoma.) 

-  Coagulation  (thrombosis)  may,   how- 

_-^;l^,'  ever,    occur   in   the   vessels   involved  in 

the  stasis,  and  the  part  be  later  removed 

Inflammatory  edema  of  skin,     through  the  proccss  of  resorption.     (See 

The  large  spaces  shown  were  .  c    /ii    ,  n      Txr- ,  i      ,  i        •    n 

filled  with  exuded  fluid.     X      Resorption  or  Clot.)     With  the  mtlam- 
2.5.    (Boyd.)  mation  fully  established  there  are  in  the 

tissue  the  following  elements:  (1)  Leuko- 
cytes and  some  red  corpuscles  and  lymphocytes  from  the  tissue 
lymphatics.  (2)  Coagulable  IjTiiph.  (3)  Later  new  embryonic  cells 
formed  by  mitosis  from  preexisting  connective-tissue  cells  which 
surround  the  leukocytes  massed  about  the  irritant.  These  are 
fibroblasts  ready  to  form  scar  tissue — i.  e.,  they  are  the  elements 
composing  granulation  tissue. 
The  disposition  of  these  elements  of  inflammation  is  as  follows: 

1.  The  leukocj^tes  mass  about  the  irritant,  exert  a  certain  amount  of 
phagocytic  activity  (ferment  action),  and  may  in  turn  be  injured, 
liberating  thrombin,  which,  acting  upon  the  fibrinogen  of  the  lymph, 
produces  fibrin,  which  in  turn  forms  a  coagulum  (see  page  25). 
This  coagulum  blocks  the  lymphatic  vessels  leading  from  the  part 
involved,  thus  causing  a  retention  of  fluid  in  the  tissue.  This  is  the 
area  involved  in  the  stasis. 

2.  In  the  later  stages  of  non-infective  inflammation  the  tissue  cells 
undergo  multiplication,  forming  cells  larger  and  having  more  power 


INFLAMMATION 


39 


of  ameboid  movement  and  phagocytosis  than  the  leukocytes.  These 
become  mingled  with  the  leukocytes  in  the  area  of  inflammation. 
They  are  fibroblasts  from  which  all  the  connecti\'e  tissues  de\'elop, 
and  to  the  action  of  which  regeneration  is  mainly  due.  The  zone 
containing  these  elements  is  in  a  less  degree  of  irritation  and  stasis 
and  may  be  called  the  area  of  lesser  inflammation. 

3.  Around  the  area  of  lesser  inflammation  the  bloodvessels  are 
in  a  condition  of  arterial  hj^eremia,  about  this  is  an  area  of  normal 
tissue.    These  areas  shade  off  into  each  other. ^ 

Fig.   11 


Acute  bronchial  catarrh :  Passage  of  leukocytes  through  the  epitheHum  of  the  bronchus 
between  the  ciliated  cells.      X  700.     (Thoma.) 

4.  The  phagocytes  cause  dissolution  of  coagula  and  dead  aseptic 
tissue,  and  remove  them.  If  the  irritant  be  thus  removable  it  is  eaten 
away  and  absorbed  by  the  lymphatics.  If  the  dead  tissue  be  super- 
ficial, the  connection  with  the  living  tissue  beneath  is  thus  dissolved 
and  the  latter  sloughed  off.  If  the  superficial  tissues  have  been  pre- 
viously removed,  the  wound  is  covered  with  the  exudates  and  leuko- 


1  Fig  13  serves  to  illustrate  these  areas,  excepting  the  fact  that  the  central  area  of 
pus  is  absent  and  occupied  entirely  by  an  area  there  termed  stasis,  as  in  this  variety 
of  inflammation  pus  is  absent. 


40  DISTURBANCES  OF  THE  VASCULAR  SYSTEM 

cytes,  which  dry  into  a  scab,  beneath  which  regeneration  occurs.  If 
mflammation  occur  in  a  mucous  surface,  the  exudate  and  corpuscles 
escape  from  the  submucous  tissue  between  the  epitheHal  cells  as  a 
catarrhal  discharge  (Fig.  11).  This  may  be  due  to  infective  causes. 
If  the  inflammatory  exudate  be  highly  coagulable  and  coagulate,  firm 
swelling  is  caused,  apt  to  lead  to  organization  of  tissue,  hence  called 
fibrinous  inflammation.  If  it  be  productive  of  hypertrophy,  it  is  called 
productive  inflammation.  This  new  tissue  being  hard  it  is  termed 
induration.  If  the  exudate  be  watery,  poor  in  albumin,  and  hence 
not  readily  coagulable,  the  inflammation  is  called  serous  inflammation. 
In  the  later  stages  of  simple  inflammation  the  coagula  are  dissolved, 
the  leukocytes  undergo  fatty  degeneration,  and  both  are  absorbed, 
together  with  such  tissue  as  has  undergone  liquefaction.  The  lympho- 
cytes and  embryonic  cells  push  into  the  area  and  regenerate  the  tissue. 
This  is  the  phenomenon  of  resolution. 

Symptoms  of  Simple  Inflammation. — These  are: 

1.  Redness  due  to  the  excess  of  blood  in  the  vessels  and  in  the  tissue. 
In  some  cases  the  part  may  have  a  dusky  hue.  The  color  is  deepest 
in  the  area  of  greatest  stasis. 

2.  Heat  due  to  the  increased  oxidation  in  the  area  of  hyperemia 
about  the  area  of  stasis.  It  has  been  shown  that  there  is  no  increased 
heat  in  the  area  of  stasis.    In  this  area  chemical  action  is  lessened. 

3.  Swelling  due  to  the  excess  of  blood  in  the  vessels,  the  exudates 
of  leukocytes  and  fluid,  and  the  multiplication  of  tissue  cells.  The 
hardness  of  a  swelling  is  due  to  coagulation  of  the  fluid  exudate. 

4.  Pain. — The  result  of  the  pressure  of  the  effusion  upon  sensory 
nerve  terminals  and  their  hyperesthesia  (see  page  34) ;  it  is  frequently 
throbbing  m  correspondence  with  the  heartbeat;  the  impulse  causes 
temporarily  increased  pressure  upon  the  nerve  terminals.  Gravita- 
tion also  mcreases  the  pressure  and  pain  in  a  dependent  part — e.  g., 
in  a  hand  or  foot  or  in  recumbency  in  case  of  pulpitis  (which  see). 

5.  Impaired  function  is  an  evident  result  of  a  disturbance  involving 
such  pathological  phenomena  as  have  been  described.  The  part 
cannot  be  used  owing  to  pain  and  stiffness  due  to  the  swelling,  also 
nutrition  of  any  part  being  impaired,  it  loses  its  normal  function. 

There  are  certain  adjmictive  symptoms,  such  as  hypercementosis, 
osteosclerosis,  which  are  evidences  of  continued  arterial  hyperemia 
(see  page  49) ;  these  results  are  mainly  due  either  to  arterial  hyper- 
emia as  such,  or  to  the  arterial  hyperemia  which  is  associated  as  an 
outer  zone  (or  first  stage)  of  all  true  mflammations  (see  Fig.  13).  In 
like  manner  resorption  of  bone  (osteoporosis)  or  tooth  substance  are 
associated  with  the  zone  of  inflammation  called  lesser  inflammation 
(see  page  39).  It  does  not  matter  if  the  inflammation  be  of  septic  origin 


INFLAMMATION  41 

as  there  will  always  be  these  areas  or  zones  outside  of  the  septic  area. 
In  themselves  these  areas  are  to  be  practically  regarded  as  aseptic 
and  to  be  functioning  under  such  conditions  even  though  the  central 
area  be  septic. 

There  are  no  general  disturbances  in  simple  inflammation  beyond  a 
slight  traumatic  fever  due  to  absorption  of  some  aseptic  material 
from  the  seat  of  inflammation — e.  g.,  thrombin.^  There  may,  how- 
ever, be  general  disturbance  due  to  pain,  loss  of  sleep,  appetite,  etc. 
Shock  due  to  widespread  inflammation,  as  from  burns,  may  be 
serious. 

Infective  Inflammation.  —  If  microorganisms  enter  the  tissue 
through  a  wound  or  puncture  or  an  abraded  surface,  or  invade  a  hair 
follicle,  or  if  they  locate  upon  predisposed  or  non-resistant  mucous 
membrane,  their  multiplication  causes  irritation  and  inflammation  of 
the  tissue  about  them,  probably  a  chemical  effect  of  their  enzymes. 
This  at  first  resembles  a  simple  inflammation,  but  later  becomes 
more  severe,  prolonged,  and  may  spread  into  the  surrounding  tissue, 
or  in  some  cases  cause  inflammation  in  another  place  in  no  way 
connected  with  it  except  by  the  blood  or  lymphatic  channels  (metas- 
tasis). Briefly  the  process  may  be  described  as  beginning  with  the 
entrance  or  location  of  the  organisms  and  their  multiplication.  An 
injury  of  the  vessel  walls  and  degeneration  of  some  tissue  occur 
and  the  phenomena,  such  as  occur  in  simple  inflammation,  begin. 
There  is  arterial  hyperemia,  later  retardation  of  the  blood  current; 
emigration  of  leukocytes  occurs,  and  a  copious  exudate  of  coagulable 
lymph  is  poured  out  into  the  perivascular  tissue.  This  is  supposed 
to  be  Nature's  method  of  limiting  suppuration,  etc.,  to  a  limited  area. 
By  positive  chemotaxis  the  leukocytes  are  attracted  to  the  bacteria, 
surround  them,  and  apparently  endeavor  to  limit  their  activity,  or, 
perhaps,  to  digest  them.  If  the  bacteria  be  few  in  number  and  not 
too  virulent,  the  phagocytes  are  successful  and  the  phenomena  of 
resolution  occur.  If,  however,  the  contrary  be  the  case,  the  leuko- 
cytes are  overcome  and  the  inflammation  spreads.  In  case  of  much 
toxin  formation,  negative  chemotaxis  occurs  and  phagoc^^tic  phe- 
nomena are  held  in  abeyance.  The  central  or  most  involved  area  dies. 
It  is  thus  seen  that  there  may  be  two  terminations  of  an  infective 
inflammation — resolution  and  necrosis.  In  certain  cases  what  is 
termed  subacute  inflammation  occurs  as  in  arthritis,  in  which  no 
necrosis  beyond  a  possible  molecular  or  cellular  one  (necrobiosis) 
may  occur,  though  these  are  now  attributed  to  bacterial  action 
(especially  for  Streptococcus  viridans).  What  are  termed  plasma  cells, 

1  Green's  Pathology  and  Morbid  Anatonay. 


42  DISTURBANCES  OF  THE   VASCULAR  SYSTEM 

oval  cells  having  power  of  phagocytosis,  are  found  in  the  chronic  cases. 
(See  Granuloma  for  description.) 

Resolution. — ^If  the  phagocytes  destroy  or  wall  up  the  bacteria, 
so  that  they  die  in  their  own  products  or  are  killed  by  the  protective 
juices  of  the  part  (alexins),  the  phagocytes  undergo  fatty  degenera- 
tion, the  l;yTnphatics  are  unblocked  by  liquefaction  of  the  coagulum, 
the  circvilation  is  reestablished,  the  tissue  that  has  died  is  removed 
by  resorption  and  replaced  by  scar  tissue  if  the  loss  be  considerable. 
No  evident  pus  or  externally  evident  necrosis  is  produced,  and  the 
part  exhibits  phenomena  much  like  those  of  a  simple  inflammation. 
This  is  the  only  termination  for  a  simple  (non-infective)  inflammation. 

Necrosis. — Death  of  a  part  may  result  from  infective  inflamma- 
tion, either  with  or  without  pus  formation. 

Suppuration. — If  the  irritant  in  the  tissue  consists  of  pyogenic 
organisms,  such  as  the  Staphylococcus  pyogenes  aureus  or  albus,  the 
Streptococcus  pyogenes,  the  Bacillus  pyocyaneus.  Bacillus  typhi 
abdominalis.  Bacterium  pneumoniae,  or  the  gonococcus,  pus  will 
be  formed,  provided  the  germs  be  not  killed. 

Entering  a  part,  the  bacteria  distributed  in  the  tissue  act  as  irritants 
and  excite  the  phenomena  of  inflammation  as  described.  Some  of 
the  bacteria  are  taken  up  by  the  fixed  connective-tissue  corpuscles, 
the  leukocytes,  and  the  endothelial  cells  of  the  capillaries,  and  some 
lie  free  in  the  tissue.  They  multiply  and  the  polymorphonuclear  and 
eosinophile  leukocytes  increase  in  number  by  diapedesis  and  surround 
them.  The  original  tissue  cells,  including  those  of  the  bloodvessels, 
undergo  coagulation  necrosis  as  the  result  of  the  action  of  bacterial 
ferments  and  do  not  take  up  staining  reagents  (Fig.  12).  Coagulation 
of  the  exudates  occurs.  The  leukocytes  and  tissue  cells  are  in  part 
degenerated  into  pus  corpuscles  by  the  action  of  the  unorganized 
ferments  of  the  bacteria — i.  e.,  their  nuclei  are  fragmented,  and  they 
undergo  fatty  degeneration.  Some  bacteria  die.  The  exudate  is 
peptonized  into  a  fluid,  which,  together  with  the  bacteria,  dead 
leukocytes  (pus  corpuscles),  and  tissue  remnants,  constitutes  pus. 
About  this  pus  is  a  circumvallating  wall  of  living  leukocytes  (area  of 
stasis,  Fig.  13),  and  about  this  again  a  zone  of  fibroblasts  arranged 
about  new  capillary  loops  (granulation  tissue),  leukocytes  are  abun- 
dant and  circulation  more  free  (area  of  lesser  inflammation).  The 
whole  constitutes,  when  confined  within  tissue,  an  abscess.  When 
upon  a  surface  the  area  of  stasis,  etc.,  is  upon  the  under  side  only, 
the  whole  constitutes  a  suppurating  ulcer. 

While  the  leukocytes  may  overcome  the  bacteria,  the  reverse  is 
often  the  case,  and  the  pus  cavity  enlarges  in  the  same  manner  as  at 
first  by  a  new  formation  of  coagulation  necrosis,  more  cir  cum  vail  ation, 


INFLAMMATION 


43 


further  liquefaction  of  the  coagulum,  etc.    The  path  offering  the  least 
vital  or  mechanical  resistance  is  usually  followed  until  the  surface  of 


Fig.   12 


Miliary  abscess  in  a  case  of  septic  embolism  of  the  kidney:  a,  leukocytes  advancing 
toward  and  surrounding  (b)  a  mass  of  cocci,  in  whose  neighborhood  all  trace  of  struc- 
ture has  disappeared;  c,  renal  epithelium  too  damaged  by  bacterial  products  to  take 
the  stain;  d,  kidney  tissue  staining  normally;  e,  vein  from  which  leukocytes  are 
making  their  way  to  the  commencing  abscess.     X  100.     (Green.) 


the  body  or  some  internal  cavity  is  reached.  The  last  portion  of 
tissue  overlying  the  forming  pus  is  tumefied  and  a  soft,  yellow  spot 
appears.     This  is  called  pointing.     The  tissue  is  ruptured  by  the 


44      ■         DISTURBANCES  OF  THE   VASCULAR  SYSTEM 

internal  pressure  and  the  pus  escapes.  The  tract  from  the  point  to  the 
abscess  cavity  is  &  fistula  or  sinus.  As  soon  as  this  occurs  granulation 
tissue  springs  up  upon  the  sides  of  the  abscess  cavity  and  usually 
soon  fills  it  with  scar  tissue.  (See  Regeneration.)  If  the  cause  con- 
tinues to  act,  as,  for  example,  in  case  of  a  portion  of  dead  and  septic 
bone  beneath  soft  tissue,  a  gangrenous  pulp  in  a  tooth  root  or  infected 
cn'pts  of  the  abscess  walls,  the  granulation  tissue  continuously  breaks 
down,  and  the  condition  is  one  of  ulceration  or  a  chronic  abscess  with 
a  fistula.  If,  in  the  course  of  abscess  formation,  bone  be  encountered 
by  the  pus,  it  may  be  and  often  is  molecularly  broken  down  into  pus 
(see  Acute  Apical  Abscess),  or  the  medullary  tissue  alone  may  be 
liquefied  (osteomyelitis  forming  caries  of  bone),  or  a  considerable 
portion  of  bone  may  be  included  in  a  profound  surrounding  mflamma- 
tion,  die  and  be  sequestered.  (See  Necrosis  of  Bone.)  It  does  not 
always  happen  that  the  pus  finds  escape  either  naturally  or  through 
surgical  aid;  the  patient  may  die  before  this  occurs,  or  the  tissues 
around  the  seat  of  pus  formation  may  form  a  boundary  wall  which 
the  bacteria  fail  to  break  down  and  thus  die  starved  out.  The  abscess 
contents  may  undergo  changes  resulting  in  caseation,  or  later  the  mass 
may  calcify.  In  tubercular  caseations  the  tubercle  bacilli  may  live 
for  a  long  period.  The  Streptococci  pyogenes  may  multiply  laterally, 
following  the  subcutaneous  cellular  tissue,  and  produce  violent 
spreading  inflammation  with  but  little  pus  formation — e.  g.,  some 
forms  of  apical  abscess  and  erysipelas. 

The  products  (toxins)  from  an  abscess  or  infective  inflammation 
may  find  their  way  into  the  blood,  and  a  general  toxemia  result,  or  the 
bacteria  themselves  may  enter  the  blood  and  a  general  infection 
result  (septicemia).  There  are  various  varieties  of  pus  which  have 
names  describing  the  chief  characteristics : 

Creamy  pits  is  the  so-called  laudable  pus  associated  with  an  acute 
abscess  or  ulcer  which  progresses,  as  a  rule,  toward  a  cure.  It  is  of 
a  yellowish-white  color,  creamy  consistency,  and  without  much  odor. 
Some  surgeons  prefer  that  this  occur  in  certain  conditions  as  being 
a  sign  of  circumvallation  by  the  defensive  living  parts  and  a  lique- 
faction of  the  tissue  containing  multiplying  bacteria  not  readily 
removable  by  anything  short  of  ablation. 

Curdy  pus  contains  flakes. 

Ichoroiis  pus  is  thin,  odorous,  and  irritating. 

Mucopus  is  pus  containing  mucus. 

Seropu^  is  pus  containing  much  serum. 

Sanious  pus  contains  blood. 

Symptoms. — The  symptoms  of  suppuration  are  both  general  and 
local. 


INFLAMMATION 


45 


Local  Symptoms. — The  symptoms  of  inflammation — redness,  heat, 
pain,  and  swelHng — occur,  but  usually  much  aggravated.  The  pain  is 
often  of  a  lancinating  character,  sudden  darts  often  following  com- 
parative quiescence.  On  the  other  hand,  the  throbbing  pain  may 
be  continuous  and  intense,  especially  when  the  pus  is  confined  by  bone 
or  tense  tissues,  as  in  the  case  of  a  felon  or  an  acute  apical  abscess. 
Recalling  that  around  the  pus  area  there  is  an  area  of  stasis,  next  one 
of  active  but  lesser  inflammation,  and  about  that  hyperemic,  then 
normal  tissue  (Fig.  13),  one  may  judge  of  the  degree  of  involvement 
of  deeper  parts  by  the  appearance  of  the  surface  above  them.  Thus, 
for  example,  hyperemia  at  the  surface  indicates  inflammatory  action 
directly  beneath,  with  a  pus  cavity  still  deeper,  while  inflammation 


H- 


■^N.T 


An  abscess  in  the  skin.  The  horny  layer  has  largely  disappeared,  and  the  Malpig- 
hian  layer  is  pushed  upward  by  the  subjacent  abscess  (a).  The  mass  of  pus  corpuscles 
is  just  breaking  down  to  form  a  cavity  (P),  the  walls  of  which  are  thickly  infiltrated 
with  similar  cells  or  the  area  of  stasis  (5).  Outside  is  the  area  of  lesser  inflammation 
(LI),  and  still  farther  away  are  the  areas  of  arterial  hyperemia  (H)  and  normal  tissue 
(N.T).    Interpretation  modified  by  editor.     (Boyd.) 


at  the  surface,  together  with  hardness  and  tumefaction,  shows  a  more 
involved  condition  of  the  tissue  directly  beneath  it — i.  e.,  a  more 
advanced  state  of  inflammation  or  even  of  suppuration. 

The  softening  of  the  apex  of  the  swelling  gives  a  feeling  of  lessened 
resistance,  indicating  pointing  or  pus  at  the  surface.  In  large,  super- 
ficial abscesses  the  sensation  known  as  fluctuation  may  be  obtained  by 
placing  one  finger  on  one  side  of  the  swelling  and  gently  tapping  upon 
the  other.  Yellowness  of  the  apex,  together  with  softness,  indicates 
that  the  abscess  is  about  to  discharge  its  contents.  A  fistula  or  sinus 
upon  the  surface  is  indicative  of  a  discharged  abscess,  and  leads  to  the 
pus-forming  area  beneath  (chronic  abscess).  The  symptoms  will  be 
modified  by  the  anatomy  of  the  part.    In  the  case  of  the  teeth  adjunc- 


46  DISTURBANCES  OF  THE   VASCULAR  SYSTEM 

tive  symptoms  are  valuable  and  will  be  considered  in  detail.  (See 
Pulp  Diseases  or  Pericementitis.)  The  adjunctive  symptoms  referred 
to  on  page  40  should  here  be  considered. 

General  Stniptoms. — If  toxemia  be  produced  there  may  be  chills, 
and,  at  the  same  time,  fever  as  high  as  104°  F.  A  full,  bounding  pulse 
accompanies  this,  the  patient  is  constipated,  has  a  coated  tongue,  is 
exhausted  by  loss  of  sleep  and  appetite  and  often  disturbed  nutrition 
due  to  the  pam.  There  may  be  other  evidences  of  septic  intoxication, 
such  as  recurring  rigors  (chills),  pallor,  nausea,  vomiting,  headache, 
diarrhea,  a  fluttering  weak  pulse  and  clammy  extremities,  with 
increasing  debility,  which  indicates  toxic  effects  which  call  for  surgical 
eradication  of  pus  foci  and  blood  antiseptics.  Thus,  for  example, 
an  abscess  on  a  lower  molar  developing  swelling  in  the  submaxillary 
region  without  development  upon  either  side  of  the  gum  and  asso- 
ciated with  the  said  s^nnptoms  of  debility,  calls  for  extraction,  local 
disinfection  and  drainage  and  blood  antiseptics,  such  as  mercuric 
chlorid,  ferric  chlorid,  hexamethylenamin,  etc.,  to  which  reference  will 
be  made  in  place.     (See  Index.) 

Leukocytosis  after  surgical  disease  is  considered  pathognomonic 
of  suppuration,  the  count  running  up  to  15,000  or  20,000  or  more 
per  cubic  millimeter.     (See  page  23.) 

The  logical  conclusions  of  a  case  not  recovering  from  a  local  infec- 
tion are : 

1.  An  acute  toxemia. 

2.  An  acute  septicemia. 

•3.  A  chronic  toxemia  or  septicemia  which  may  be  a  combination 
of  both. 

Ulceration. — This  is  a  loss  of  epithelial  surface  extending  into  the 
corium.  The  development  of  microorganisms  upon  a  free  surface 
causes  tissue  degeneration  and  death,  as  described  on  page  41. 

Numerous  forms  of  pathogenic  organisms  are  capable  of  causing 
tissue  degeneration  and  death  of  a  mucous  or  skin  surface.  If  infec- 
tion take  place  through  a  hair  follicle,  or  if  organisms  develop  upon  an 
abrasion,  or  in  the  epithelium  in  conditions  of  general  or  local  debility, 
the  epithelium  is  destroyed  over  an  area,  and  in  the  subepithelial 
tissues  the  organisms  multiply  and  cause  tissue  loss.  If  the  organisms 
be  pyogenic — and  ulcerous  surfaces  are  usually  infected  by  these 
bodies — pus  is  formed  (Fig.  14).  Under  some  conditions,  as  in 
debilitated  and  neglected  children,  the  ulcerous  process  may  spread 
rapidly,  as  in  the  cheek  in  cancrum  oris;  or  when  specific  bacilli, 
which  excite  much  swelling  and  quick  death  of  the  tissues  of  the 
cheek,  proliferate,  causing  the  condition  called  noma.     (See  Index.) 


INFLAMMATION 


47 


Acute  Toxemia. — The  poisons,  theoretically,  may  alone  invade  the 
blood,  producing  in  some  diseases  death  by  intoxication  (action  on 
body  cells  in  general),  e.  g.,  tetanus  or  diphtheria. 
i.  Acute  Septicemia. — The  bacteria,  and  the  toxins  usually  as  well, 
enter  the  blood,  produce  a  clumping  of  red  corpuscles  at  certain 
points  in  the  capillaries,  develop  in  the  local  focus,  and  spread  their 
toxins  tlu-ough  the  system;  the  spleen  is  usually  enlarged,  the  red 
corpuscles  disintegrated,  the  lungs  congested  and  the  heart  finally 
fails.  The  s;\Tnptoms  of  debility  given  on  page  46  are  followed  by 
delerium,  coma  and  death. 

Fig.   14 


Tuberculous  ulcer  of  the  intestine:   a,  mucosa;   I,  submucosa;   c,  muscularis;  g,  ulcer; 
t,  tubercle  in  the  mucosa;   t',  focus  caseating  in  the  middle.      X  12. 


Pyemia. — This  is  a  modification  of  septicemia  in  which  pyogenic 
organisms  from  some  original  focus  locate  at  many  points  forming 
multiple  abscesses,  which  interfere  with  local  function,  act  as  foci 
of  further  infection  (metastasis)  and  toxemia  and  almost  invariably 
produce  death  as  in  septicemia;  occasionally  it  becomes  chronic. 

Chronic  Infection. — Certain  bacteria  developing  in  dental  abscesses, 
pyorrhea  pockets,  the  tonsils,  the  appendix  vermiformis,  etc.,  and  of 
modified  virulence  seem  to  possess  the  power  of  forming  either  sup- 
purative metastatic  infections,  such  as  furuncle,  appendicitis,  arthritis, 
endocarditis  or  non-suppurative  diseases  representing  an  infection 
transferred  from  the  original  focus  and  which  may  be  of  chronic 
nature  yet  seriously  endangering  life  through  the  secondary  disease 
produced.  This  will  be  considered  •  at  length  in  a  later  chapter. 
(See  Blind  Abscess.) 


48  DISTURBANCES  OF  THE   VASCULAR  SYSTEM 

INFLAMMATION    OF   BONE. 

"Active  inflammatory  changes  may  occur  in  the  periosteum,  the 
medullary  canal,  the  medullary  spaces  of  the  spongy  bone,  and 
the  Haversian  canals,  the  compact  tissue  and  ground  substance 
remaining  passive."^  The  inflammation  is  termed  periostitis,  osteo- 
myelitis, or  osteitis,  the  terms  referring  to  the  point  of  location  of 
the  inflammation — i.  e.,  the  periosteum,  the  medulla,  and  the  spaces 
— the  bone  being  involved  in  all  cases.  Inflammation  of  bone  may 
be  non-infective  or  infective;  the  latter  is  usually  due  to  pyogenic 
organisms — i.  e.,  suppuration  occurs. 

Proliferative  Periostitis. — This  is  a  proliferation  of  cells  of  the 
deeper  layers  of  the  periosteum  combined  with  emigrated  leukocytes. 
A  node  is  thus  formed  which  may  ossify.  Practically  it  may,  like 
hypercementosis,  be  regarded  as  a  lesser  inflammatory  area  (Fig.  13), 
an  aseptic  mild  inflammation  in  which  the  area  of  hyperemia  is  the 
proximate  constructive  element. 

Suppurative  Periostitis. — Pyogenic  organisms  may  enter  an 
injured  periosteum  or  one  weakened  by  previous  disease  {e.  g.,  by 
scarlet  fever).  The  origin  of  the  bacteria  is  by  way  of  the  blood, 
either  directly  or  by  way  of  the  medulla  (as  a  secondary  effect  of 
osteomyelitis),  or  by  way  of  the  skin.  It  may  occur  as  in  a  dental 
mucous  anesthesia  performed  intraperiosteally  with  a  septic  needle. 

Pus  forms  beneath  the  periosteum,  raises  it,  and  destroys  its 
connection  with  the  bone.  The  vessels  are  stretched,  damaged,  and 
thrombosis  occurs.  Superficial  necrosis  of  bone  results,  which  may 
be  total  if  other  sources  of  blood  supply  are  also  cut  off. 

Acute  Osteomyelitis. — This  is  a  suppuration  occurring  in  the 
bone-marrow,  which  infects  the  bone  proper,  causes  much  throm- 
bosis of  vessels,  coagulation  necrosis  of  bone  cells,  and  may  rapidly 
cause  much  necrosis  of  medullary  tissue.  Occurring  in  large  bones, 
much  toxin  is  produced,  which  may  rapidly  cause  death.  The  organ- 
isms and  thrombi  formed,  becoming  emboli,  may  rapidly  lead  to 
pyemia.2    Prompt  surgical  interference  is  called  for. 

Inflammation  of  bone  may  lead  to  its  rarefaction  (rarefying 
osteitis  or  osteoporosis),  its  condensation  (condensing  osteitis  or 
osteosclerosis),  or  its  death  (necrosis  and  caries). 

Rarefying  Osteitis  (Osteoporosis). — In  the  rarefying  process 
which  occurs  in  chronic  inflammation,  granulation  tissue  is  formed, 
(for  practical  teaching  purposes  a  more  or  less  aseptic  area  of  lesser 
inflammation),  which  enters  the  Haversian  canals  and  spaces  of 

1  Schmaus  and  Ewing,  Pathology  and  Pathological  Anatomj\ 

2  Park's  Surgery. 


INFLAMMATION  OF  BONE 


49 


spongy  bone  and  destroys  (resorbs)  the  bone,  owing  to  the  presence 
of  osteoclasts.    They  thns  form  new  channels  between  the  spaces — 
'perforating  canal  resorption  (Fig.  15).     When  suppuration  (ulcera- 
tion) is  added  by  entrance  of  bac- 
teria, the  granulations  break  down, 
leaving  the  bone  as  a  dead,  spongy, 
or   honeycombed  mass.      This   is 
caries  of  hone.    In  the  early  stages 
the  inflammation  may  cease,  and 
the  bone  not  only  be  restored,  but 
condensed. 

Condensing  Osteitis  (Osteoscler- 
osis).— In  chronic  inflammation, 
of  lesser  degree,  instead  of  rarefac- 
tion, construction  occurs  and  the 

trabecule  of  bone  may  increase  in  thickness,  so  that  all  spaces  and 
Haversian  canals  become  smaller.  This  is  due  to  the  area  of  arterial 
h\'peremia,  which  for  practical  teaching  purposes  the  writer  asso- 


FiG.   15 


'-^ 


Trabeculae   of  bone   with  perforatia^ 
canals.      X  50. 


Fig.  16 


Fig.   17 


/> 


^ 


^    i^  * 


Section  of  bone  and  periosteum  cover- 
ing it:  B,  bone;  c,  outer  fibrous  layer; 
a,  inner  layer  of  white  fibrous  tissue;  O, 
layer  of  osteoblasts,  some  of  which  reach 
the  bone  with  their  prolongations.  Nor- 
mal bone.     (Black.) 


Section  of  bone  and  periosteum 
covering  it:  a,  osteoclasts,  cells  that 
absorb  bone;  6,  surface  of  bone, 
showing  fibers  of  periosteum  pene- 
trating it  and  a  Howship  lacuna. 
Lacunar  resorption.     (Black.) 


ciates  with   Constructions.     The  bone  becomes  very  compact  and 
less*!  vascular,  and  if  built  up  in  excess  of  its  original  dimensions, 
constitutes  the  condition  known  as  exostosis;  if  very  dense,  as  "ivory 
4 


50 


DISTURBANCES  OF  THE   VASCULAR  SYSTEM 


exostosis."  Both  condensing  and  rarefying  osteitis  occur  about  the 
alveolar  process  and  the  roots  of  teeth.  (See  H^'percementosis  and 
Resorption.) 

Resorption  of  Bone. — Under  conditions  of  chronic  inflamma- 
tion bone  is  often  removed  by  neighboring  tissue  in  one  of  several 
ways. 

Lacunar  Resorption. — In  this  form  the  bone  is  excavated  by  giant 
cells  into  bays  called  Howship's  lacunae,  which  may  enlarge,  or  later 

a   reconstructive  action   may 
Fig.  18  occur  and  osteoblasts  may  fill 

up  the  bays  with  bone.  (See 
Fig.  17  and  Resorption  of 
Roots.) 

Perforating  Canal  Resorption. 
— This  has  been  described  un- 
der Osteoporosis.  The  canals 
connecting  medullary  spaces 
are  enlarged  by  the  granula- 
tion tissue  formed  in  them 
(Fig.  15). 

Halisteresis  Ossium. — In  this 
form  of  resorption  the  bone 
first  undergoes  decalcification  and  the  matrix  is  later  removed  (Fig. 
18).  It  occurs  in  conditions  of  osteomalacia,  as  in  pregnancy,  senility, 
etc.  It  also  occurs  in  the  alveolar  process,  and  is,  at  least  in  part, 
the  cause  of  the  cleanly  symmetrical  resorption  of  the  gum  and 
alveolar  margins.    (Talbot.^) 


Lattice-work  figures  in  halisteresis. 
V.  Recklinghausen.) 


(After 


NECROSIS. 

Necrosis  (from  nekros,  dead)  signifies,  in  its  broadest  sense,  death 
of  tissue.  It  is  due  to  profound  disturbance  of  its  nutritional  function 
or  to  direct  injury  to  its  elements. 

Necrosis  proper  (per  se)  signifies  death  of  tissue  in  mass  from  any 
cause. 

Necrobiosis  means  the  death  of  cells  through  the  process  of 
atrophy  or  degeneration,  which  are  successive  changes  leading  to 
death.    It  is  also  spoken  of  as  molecular  death  of  tissue. 

Necrosis  of  bone  signifies  the  circumvallation  and  death  of  bone 
through  the  process  of  inflammation,  which  causes  thrombosis  of 
its  vessels  and  cessation  of  its  nutrition.  The  dead  part,  when 
separated,  is  called  a  sequestrum.     The  solution  of  continuity  is 


•  Interstitial  Gingivitis. 


NECROSIS  51 

effected  by  leukocytes  massed  about  the  portion  in  which  nutrition 
has  ceased.  New  bone,  growing  from  the  hving  bone,  and  inclosing 
a  sequestrum  is  termed  an  "involucrum,"  a  marked  example  occurring 
in  phosphor-necrosis  (which  see).  The  necrosed  portion  is  hard  but 
may  have  undergone  osteoporosis  and  when  sequestered  is  movable; 
usually  a  fistula  forms. 

Caries  of  bone  is  that  form  of  bone  death  in  which  the  bone  is 
honeycombed  and  molecularly  broken  down  rather  than  seques- 
trated. (See  Osteoporosis.)  The  part  is  not  sequestered  and  is 
readily  penetrated  by  a  stiff,  sharp  probe;  one  or  more  fistula  are 
usually  present. 

Fig.    19 


Senile  gangrene  of  the  great  toe,  from  a  case  of  arterial  thrombosis.  The  toe  is 
shrunken  and  its  epidermis  is  being  exfoliated.  At  the  line  of  demarcation  the  skin 
has  retracted  (a)  and  the  deeper  parts  are  separating  (6).     (Green.) 

Gangrene  is  a  term  used  to  signify  death,  en  masse,  of  a  part, 
through  interference  with  its  circulation,  the  hard  parts  being  m- 
cluded.  The  dead  part  later  undergoes  drying  or  mmnmification  (dry 
gangrene)  or  putrefactive  softening  (moist  gangrene)  under  the  action 
of  bacteria.  The  death  may  occur  through  (1)  purely  circulatory 
disturbances  cutting  off  nutrition,  (2)  through  disease  of  controlling 
nerves  or  (3)  through  direct  destruction  by  mechanical  or  chemical 
agents  including  the  effects  of  bacteria.  The  dead  part  is  sequestered 
b}^  a  zone  of  leukocytes  as  a  "  slough"  or  "sphacelus,"  which  is  thrown 
off.  Strictly  speaking  gangrene  occurs  at  the  moment  death  of  the 
tissue  occurs  and  the  tissue  may  at  that  moment  be  aseptic  as  in  the 
case  of  a  pulp  going  through  venous  hj-peremia  {q.  v.) .  Therefore  dr}'' 
and  moist  gangrene  are  not  strictly  mummification  and  putrefaction 
though  these  later  ensue.  The  dry  form  is  due  to  stoppage  of  the 
artery  causing  ischemia,  the  moist  form  to  stoppage  of  the  vein 


52  DISTURBANCES  OF  THE  VASCULAR  SYSTEM 

causing  venous  hyperemia.  Bacteria  entering  the  dead  portion  may 
infect  and  involve  the  surrounding  tissue  in  a  "spreading  gangrene" 
or  the  hving  tissue  may  estabHsh  a  line  of  demarcation  consisting 
of  protective  leukocytes,  which  dissolve  the  connecting  tissue  and 
separate  the  dead  portion,  as  in  the  case  of  sequestered  bone.  The 
dead  portion  so  separated  is  called  a  "slough"  or  "sphacelus."  This 
is  "circumscribed  gangrene." 

In  the  aged  atheromatous  or  calcareous  changes  in  the  arteries 
produce  a  slow  circulation  in  the  extremities.  A  slight  injury  to  a 
vessel  wall  may  induce  extensive  thrombosis  (which  see) .  The  result 
is  gangrene  of  a  part  or  all  of  an  extremity,  known  as  senile  gangrene 
(Fig.  19). 

Necrosis  may  be  of  several  types,  of  which  the  following  are  the 
chief  forms: 

Coagulation  Necrosis. — When  a  dying  tissue  contains  coagulable 
material  and  the  necessary  ferments,  the  parts  undergo  coagulation. 
(See  Coagulation.)  The  cells  and  parts  about  become  solidified,  the 
cells  lose  their  nuclei  and  do  not  stain  as  usual,  and  the  part  appears 
glazed,  pale,  and  waxy.  It  occurs  in  suppuration,  and  is  due  to  the 
coagulating  ferments  of  pyogenic  cocci.  (See  Bacterial  Ferments; 
also  Fig.  12.) 

The  thrombosis  of  the  vessels  about  an  area  of  infective  inflam- 
mation is  probably  due  to  the  same  ferments. 

Fat  Necrosis. — This  is  a  peculiar  form  of  fat  death  in  which  the  fat 
is  split  into  glycerin  and  fatty  acid  by  lipase  (a  ferment).  The  fatty 
acid  remains  and  combines  with  inorganic  salts. 

Liquefaction  Necrosis. — This  is  the  death  of  tissue  with  liquefaction 
of  the  proteid  material  in  the  area,  which  is  usually  rich  in  exudates. 
The  process  is  probably  due  to  enzymes  capable  of  liquefying  the 
tissue. 

Necrobiosis,  Necrosis  Proper,  Gangrene  as  described. 

REGENERATION  OF  TISSUES. 

Connective  tissues  that  have  been  lost  by  inflammatory  process  or 
surgical  operation  are  replaced  by  granulation  tissue  arising  by  mitotic 
division  of  cells  of  the  connective-tissue  group.  The  forms  of  healing 
are  (1)  by  first  intention,  (2)  second  intention  or  granulation,  (3) 
healing  under  a  scab,  (4)  healing  under  a  clot.  Epithelial  tissues  are 
replaced  only  by  multiplication  of  epithelial  cells.  The  forms  of  heal- 
ing are  practically  alike  by  formation  of  granulation  tissue,  the  form 
bemg  simply  a  modification  (of  extent)  of  healing  by  second  intention. 
This  granulation  tissue  is  transformed  into  fibrous  tissue,  the  original 


REGENERATION  OF   TISSUES 


53 


tissue  rarely  being  reproduced  to  any  great  extent  though  bone  may 
be  regenerated.     (See  Apicoctomy,  Apical  iVbscess,  etc.) 


Fig.  20 


Regeneration  of  capillary  bloodvessels:  a,  normal  capillaries;  b,  capUlary  process; 
c,  new  capillary  appearing  in  divided  process;  d,  process  undergoing  division;  e,  con- 
necting cell  in  which  no  sign  of  division  has  yet  appeared.    Diagrammatic.    (Green.) 


Fig.  21 


A  granulating  surface:  a,  layer  of  pus;  b,  granulation  tissue  with  loops  of  blood- 
vessels; c,  commencing  development  of  the  granulation  tissue  into  a  fibrillated  struc- 
ture.     X  200.     Diagrammatic.     (Rindfleisch.) 


54 


DISTURBANCES  OF  THE   VASCULAR  SYSTEM 


Healing  by  Second  Intention  or  Granulation. — Shortly  after  evacu- 
ation of  pus  from  an  abscess  the  process  of  repair  is  instituted.  The 
leukocj^es  come  to  the  surface  of  the  wound  in  great  numbers,  an 
exudate  of  lymph  also  occurs;  some  of  these  may  degenerate  into 
pus  cells.  Immediately  beneath  the  uninjured  connective-tissue  cells 
multiply,  forming  embryonic  cells  (fibroblasts) ;   at  the  same  time  the 


Transverse  section  of  granulation  tissue  from  an  open  wound  with  fibropurulent 
deposit:  a,  granulation  tissue;  b,  fibropurulent  deposit;  c,  c,  bloodvessels.  X  150 
(Ziegler.) 


endothelial  cells  of  the  capillaries  multiply  at  points,  throwmg  out 
solid-pointed  projections  or  buds  from  the  sides  of  the  capillaries 
Fig.  20,  b).  These  lengthen  and  join  buds  from  other  capillaries 
(Fig.  20,  c,  d,  e).  By  mitosis  the  nuclei  divide  horizontally,  lying  side 
by  side  (Fig.  20,  d).  Later  these  separate  mto  two  cells,  discovering 
a  lumen  into  which  blood  enters  from  the  parent  capillary  (Fig.  20, 


REGENERATION  OF  TISSUES 


55 


a',  c).  In  this  manner  loops  are  formed,  about  which  the  fibroblasts 
are  arranged  (Figs.  21  and  22), 

Together  these  form  minute  red  elevations  upon  the  surface  of  the 
abscess  cavity  or  wound,  called  granulations.  Repeated,  the  process 
gradually  fills  the  abscess  cavity. 

Naturally,  collapse  of  the  walls  or  apposition  of  cut  edges  of  a 
wound  lessens  the  amount  of  granulation  tissue  necessary;  hence,  in 
the  latter  case,  healing  by  first  intention  (with  a  minimum  amount 
of  granulation  or  scar  tissue) .  Even  in  a  cut  with  the  edges  constantly 
moved,  as  on  the  tip  of  a  finger,  the  area  is  gradually  obliterated  by 
second  intention. 

Fig.  23 


Laparotomy  wound — sixteenth  day :  a,  a,  epithelium;  6,  6,  corium;  c,  subcutaneous 
fat;  d,  vessels  in  scar  tissue  of  corium;  e,  newly  formed  epithelial  layer;  /,  vessels  in 
subcutaneous  scar  tissue.     X  40.     Modified  from  Ziegler.     (Green.) 


The  wound  having  been  filled  up,  epithelium  grows  from  the  sides 
and  covers  the  granulations  (Fig.  23,  e).  The  granulation  tissue,  at 
first  highly  vascular,  later  contracts,  and  many  vessels  are  obliter- 
ated so  that  it  becomes  whiter  than  normal  tissue — cicatricial  tissue 
(scar  tissue). 

The  indifferent  embryonic  cells  may  have  the  function  of  forming 
any  of  the  connective  tissues.    If  cartilage  is  to  be  formed,  chondrifi- 


56 


DISTURBANCES  OF  THE  VASCULAR  SYSTEM 


Fig.  24 


cation  takes  place  about  the  specialized  cells.  If  bone  is  to  be  formed, 
certain  cells  form  islets,  about  which  calcification  proceeds.  Nerves 
require  a  month  or  more  to  pierce  the  cicatricial  tissue  (Eichhorst).^ 
In  spite  of  this  assertion  the  writer  finds  that  granulations  are  very 
sensitive  to  touch,  which  seems  clinical  evidence  of  error  in  this 
observation. 

In  healing  beneath  a  scab  the  exudation  and  leukocytes  upon  the 
surface  of  the  womid  dry  into  a  scab  beneath  which  granulations 

and  an  epithelial  covering  are 
formed.  Later  the  scab  falls 
off,  usually  being  lost  first  at 
the  periphery  as  the  epithelium 
is  formed.  If  prematurely  lost 
the  granulations  are  exposed 
and  the  smooth  new  epithelium 
disclosed  around  the  central 
area  of  granulations. 

In  healing  imder  a  clot  the 
clot  is  invaded  by  leukocytes, 
which  have  a  solvent  action 
upon  it.  Granulation  tissue 
forms  upon  all  sides  of  it,  grows 
into  it,  and,  at  the  same  time, 
removes  it  by  resorption  (Fig. 
24).  If  the  clot  become  septic 
the  granulations  may  become 
infected  and  break  down,  as 
scar  tissue  in  its  early  vascular 
stages  is  of  but  feeble  resistive 
power,  though  it  does  not  ab- 
sorb toxins.  (Park.) 

Healing  under  a  clot  is  the 
form  commonly  seen  after  tooth 
extraction.  While  a  clot  is  the 
best  occupant  of  the  ah^eolus, 
affording  a  scaflPold  for  the  granulations,  if  the  walls  are  not  infected 
(at  least  to  the  point  of  tissue  death),  granulations  will  usually  fill 
it  up  or  nearly  do  so.  (See  Dry  Socket.)  It  is  an  interesting  point 
that  the  alveolus  is  finally  filled  with  bone,  while  the  original  bony 
margins  of  the  alveolus  are  resorbed. 

In  certain  cases  of  abscess  with  contracted  fistulse  or  openings  of 


Absorption  of  blood  clot.  Section  through 
the  margin  of  a  clot  formed  among  the  tissues 
by  extravasation,  showing  the  growth  of 
granulations  by  which  it  is  removed:  a,  a, 
portions  of  clot;  b,  b,  original  tissue;  c,  c, 
granulations  springing  from  the  original  tis- 
sue and  projecting  into  the  clot;  d,  d,  wan- 
dering cells  or  leukocytes  that  seem  to  have 
taken  red  blood  disks  into  their  ipterior. 
(Section  cut  in  gum  arabic  and  stained  with 
hematoxylin.)      X  350.     (Black.) 


1  Ziegler,  General  Pathology. 


DEGENERATION 


57 


discharge,  the  orifice  may  close  before  the  granulations  have  filled 
the  pus  cavit}'.  If  pus  or  an  excess  of  exudate  be  now  formed  within 
the  cavity,  a  second  discharge  may  occiu*.  To  obviate  this  difficult}', 
abscesses  are  often  packed  with  antiseptic  gauze,  so  that  healing  may 
occur  from  the  bottom  of  the  cavity  while  drainage  is  resumed.  In 
other  cases  the  placing  of  a  tent  or  drain  tube  in  the  fistula  suffices. 
In  other  cases,  as  in  bone  cavities,  semisolid  substances  such  as 
Beck's  bone  paste  or  bone  wax  (q.  v.)  are  introduced  to  occupy  the 
cavity  and  exclude  infective  and  foreign  material  while  granulations 
form  about  it  and  gradually  absorb  it. 

DEGENERATION. 

Degeneration  signifies  a  retrograde  process  in  cells  in  which  abnor- 
mal cell  changes  occur  in  consequence  of  disturbed  nutrition.  The 
cells  usually  gradually  die  after  marked  changes  in  their  histology. 
This  form  of  death  is  called  necrobiosis.  The  tissue,  as  a  whole,  is 
still  living. 


Fig.  25 


Fig.  26 


Liver  cells  in  various  stages  of 
fatty  accumulation.  X  300. 
(Rindfleisch.) 


Fatty  degeneration  of  cells:  a,  from  a 
cancer;  b,  from  the  brain  in  chronic  soften- 
ing.     X  200.     (Green.) 


Fatty  Degeneration. — True  fatty  degeneration,  also  called  fatty 
metamorphosis,  is  chiefly  characterized  by  the  presence  of  fat  droplets 
within  the  cells  and  formed  by  conversion  of  the  proteid  mto  fat;  it 
differs  from  fat  infiltration  in  that  m  the  latter  fat  enters  the  cells 
from  without,  and  is  a  more  or  less  physiological  process  (Figs. 
25  and  26).  The  greater  the  amomit  of  fat  in  true  fatty  degener- 
ation the  nearer  the  cell  is  to  death.  After  its  death  it  is  probably 
absorbed.  This  condition  frequentlv  occurs  in  inflammations 
(Fig.  26).         ^  ^  •     _ 

In  areas  which  have  undergone  fatty  degeneration  a  cheesy  sub- 
stance may  be  formed  out  of  the  degenerated  elements  existing 
in  the  part.    The  fluid  is  gradually  absorbed  and  a  mass  composed 


58 


DISTURBANCES  OF  THE  VASCULAR  SYSTEM 


of  atrophied  cells,  fatty  debris,  and  cholesterin  crystals  is  left.  This 
process  is  known  as  caseation  (Fig.  14,  f).  Encapsulation  of  the 
caseous  mass  by  fibrous  tissue  may  take  place,  or  its  liquefaction  or 
its  calcification  may  occur.    Fatty  degeneration  may  occur  in  many 


Fig.  27 


.^ „, —  r"^  •  3»?^^'°'     *  »       J."     •^ 


«c,i&r 


^■^.    .j 


Fatty  degeneration  of  the  heart,  from  a  case  of  pernicious  anemia.  The  protoplasm 
is  replaced  by  globules  of  various  sizes  stained  black  by  osmic  acid.  The  outlines  of 
the  fibers  are  irregular,  owing  to  inequality  in  their  distention.      X  400.     (Green  ) 


Fig.  28 


tissues,  and  the  danger  is  proportionate  to  the  importance  of  the 
tissue  involved. 

Various  other  forms  of  substances  appear  in  cells  degenerated  by 
various   causes,    such   substances   give   the    designations — amjdoid, 

mucoid,  hyaline,  fibroid,  col- 
loid degenerations.  The  ap- 
pearance of  glycogen  in  the 
cells  has  not  been  success- 
fully classified  as  either  posi- 
tively a  degeneration  or  infil- 
tration (Figs.  28  to  30). 

Cloudy  Swelling  (Parenchy- 
matous or  Granular  Degener- 
ation).— Cloudy  swelling  is  a 
change  occurring  in  the  pa- 
renchyma (essential  cells)  of 
a  part   as  the  result  of   the 
presence  of  toxic  substances  in  the  blood,  or  even  as  the  result  of 
aseptic  disturbance  of  nutrition,  such  as  a  severe  burn.     The  same 
causes  which  produce  fatty  degeneration  may  produce  it. 


Hyalin  degeneration  of  small  vessels  in  the 
cord.      X  350. 


DEGENERATION 


59 


Pathology. — The  cell  absorbs  fluid,  swells,  its  contents  become 
granular,  and  the  histological  structure  is  lost.  In  the  early  stages 
the  change  is  albuminous;  no  fat  is  demonstrable;  later,  however, 


Colloid  cancer,  showing  the  large  alveoli,  within  which  is  contained  the . gelatinous 
colloid  material.      X  300.     (Rindfieisch.) 


/       c_- 


4--' 


.J? 


a>-- 


Fig.  30 


4'" 


i 


"ett-j^r 


^^-. 


^■5,-o*C, 


K 


W 


-^ 


Cloudy  swelling  of  kidney  epithelium:  a,  normal  epithelium;  h,  epithelium  begin- 
ning to  be  cloudy;  c,  advanced  degeneration;  d,  cast-off  degenerated  epitheHal  cells. 
From  a  preparation  which  had  been  treated  with  ammonium  chromate.  X  600. 
(Ziegler.) 


60 


DISTURBANCES  OF  THE  VASCULAR  SYSTEM 


it  appears,  so  that  the  change  is  regarded  as  a  first  stage  in  the  pro- 
duction of  fatty  degeneration,  by  which  process  many  of  the  cells 
are  lost,  though  the  organ  may  recover  if  the  patient  withstands 
the  original  disease  (Fig.  30). 


Fig.  31 


Adipose  tissue:    A,  normal;    B,  atrophic,  from  a  case  of  phthisis;    a,  single  fat  cell, 
with  cell  wall,  nucleus,  and  drop  of  fat.      X  300.     (Virchow.) 


^) 


ht 


Fi°-  32  Atrophy. — ^If  hj-ponutrition  be 

marked,  the  waste  in  a  previously 
normal  part  may  exceed  repair, 
and  the  part  affected  becomes 
diminished  in  size  or  atrophied 
(Figs.  31,  B,  and  32).  Atrophy 
may  be  general  or  local.  In 
general  atrophy  there  is  a  gen- 
eral loss  of  tissue,  due  to  an 
excessive  waste  or  faulty  assim- 
ilation of  food  by  the  tissues. 
There  is  a  loss  of  body  weight, 
due  first  to  a  loss  of  the  fat,  later 
to  shrinkage  in  the  tissue  cells. 
The  shrinkage  in  size  of  the  tis- 
sue cells  causes  shrinkage  of  the 
entire  organ.  The  cells  and  fat 
may  recover  their  size  when  the 
faulty  waste  or  assimilation  is 
corrected.  During  atrophy  many 
cells  are  lost  through  the  process 
of  fatty  degeneration  and  re- 
moved by  the  phagocytes  (leuko- 
cytes), so  that  atrophy  may,  like  hypertrophy,  be  both  simple  and 
numerical.  An  atrophied  part  is  pale  and  shrunken,  contains  less 
fluid,  and  is  tough  and  fibrous.  At  times  the  fibrous  portion  or 
connective  tissue  may  increase  as  the  cells  diminish  (sclerosis). 
Practically  fibroid  degeneration  is  of  this  character  (which  see) . 


■i^^ 


Muscle  fibers  in  simple  atrophy. 
(Schmaus.) 


5fe|9t4.^:r|'g   i 


DEGENERATION 


61 


Causes.— General  atrophy  is  caused:^  (1)  By  a  deficient  supply 
of  food  material  delivered  to  the  tissue  cells.  This  may  be  due  to  a 
primary  food  deficiency  or  any  interference  with  its  preparation  for 
absorption  or  with  its  proper  absorption  or  circulation.  (2)  By 
excessive  waste  of  the  tissues  generally,  as  in  fevers,  prolonged 
suppuration,  etc.  (3)  By  impaired  vital  activity  of  the  cells  them- 
selves, as  in  senile  conditions. 


Calcareous  infiltration  of  renal  epithelia      From  the  edge  of  an  old  infarct;    a   few 
tubules  still  to  be  recognized.      X  250.     (Schmaus  and  Ewing.) 

Local  atrophy  may  be  caused:  (1)  By  a  lessened  circulation  in 
a  part  due  to  obstruction  of  the  arteries,  veins,  or  capillaries,  as, 
for  example,  by  pressure  .(see  secondary  dentin).  (2)  By  diminished 
functional  activity  or  disuse  of  a  part,  as  in  the  case  of  unused  muscles 
or  even  bones.  Certain  organs  are  atrophied  or  resorbed  as  a  part 
of  the  cycle  of  life,  e.  g.,  the  umbilical  cord,  the  roots  of  deciduous 
teeth,  the  thymus  gland,  the  mammary  glands  after  the  menopause. 
(3)  The  loss  of  nervous  connection  of  a  part  with  the  nerve  centers 
controlling  it  (trophoneurosis),  or  through  interference  with  nervous 
centers  having  trophic  influence  upon  a  part.  (4)  Excessive  functional 
activity  may  cause  atrophy  by  producing  a  degenerative  condition 
due  to  overstimulation. 

Infiltrations. — ^An  infiltration  signifies  the  entrance  into  cells  of  sub- 
stances from  without.  Thus  fatty,  pigmentary,  serous,  calcareous 
and  possibly  glycogenic  infiltrations  are  classified;  of  these  the  most 
interesting  are  the  pigmentary  (see  page  78)  and  the  calcareous. 

1  Green:  Pathology  and  Morbid  Pathology. 


62  DISTURBANCES  OF   THE  VASCULAR  SYSTEM 

Calcareous  Infiltration.  —  In  tissues  which  have  undergone  pre- 
vious degeneration,  calcium,  sodium,  or  magnesium  salts  may  be 
deposited  as  an  infiltration  from  the  blood  plasma.  The  parts  are 
thus  petrified.    The  cells  take  no  active  part  in  the  process.^ 

It  is  believed,  however,  that  the  deposit  of  salts  in  the  dying  tissue 
is  more  than  a  mere  precipitation,  and  that  calcification  results  from 
a  combination  of  the  salts  with  an  albuminous  base  and  with  fatty 
acids,  such  an  affinity  being  favored  by  the  degenerative  changes. 
Ordinarily,  the  carbonate  and  phosphate  of  calcium  are  the  infiltra- 
ting salts,  but  in  gout  uric  acid  salts  are  deposited,  owing  to  an  excess 
of  uric  acid  in  the  form  of  biurates  and  quadurates  in  the  body  fluids. 
A  sluggish  circulation  in  the  part  favors  the  deposition  of  the  salts. 
The  calcification  may  occur  in  both  the  cells  and  in  the  intercellular 
substance.^  (See  Calcific  Degeneration  of  the  Pulp.)  In  the  early 
stages  the  salts  are  found  as  fine  granules  in  the  intercellular  substance. 

"The  white,  fibrous  tissue  is  the  form  of  connective  tissue  usually 
affected,  but  concretions  may  occur  in  the  connective  tissue  sur- 
rounding the  bloodvessels."^ 

As  a  secondary  process  after  degeneration,  calcification  of  the 
middle  coats  of  the  arteries  may  occur,  rendering  them  inelastic. 
This  renders  them  incapable  of  regulating  the  blood  supply  to  parts, 
and  these  suffer  more  or  less  nutritive  disturbance,  and,  in  some  cases, 
actual  death  of  the  part  (gangrene).  Calculi  are  found  in  tumors  at 
times.  Many  forms  of  free  calculi  are  formed  in  the  body.  These 
occur  most  frequently  in  ducts  or  cavities  lined  with  epithelium, 
e.  g.,  the  salivary  ducts  and  the  bladder. 

"All  free  concretions  have  an  organic  basis  or  nucleus,"  with 
which  are  combined  the  calcium  salts,  oxalates,  cholesterin,  etc., 
making  up  the  inorganic  or  crystallizable  part  of  the  combination. 
The  organic  part  may  consist  of  inspissated  feces,  as  in  enteroliths, 
globulin  or  possibly  mucin,  as  in  the  calculi  upon  the  teeth;  epithe- 
lial scales,  mucus,  etc.,  in  the  urinary  passages.^  The  fine  crystals  or 
granules  are  probably  soluble  in  some  cases.  The  larger  calculi  are 
probably  permanent  and  cause  degeneration  of  adjacent  tissue. 

Calcareous  infiltration  is  clearly  to  be  distinguished  from  the 
normal  calcification  of  the  hard  tissues,  bone,  enamel,  dentin,  and 
cementum.  These  are  composed  of  calcoglobulin,  in  which  calcium 
and  magnesium  salts  are  combined  under  the  superintendence  of 
certain  living  cells  with  albuminous  bases  derived  probably  from 
their  own  substance.  Black's  theory  of  calculus  formation  (which 
see)  may  possibly  be  applicable,  for  if  calculus  exist  in  globules  in  the 
blood  it  could  readily  be  deposited  in  any  tissue. 

1  Green,  Pathology  and  Morbj(J  J^nf^-tgj^y, 

3  Ziegler,  General  Pathology.  '  Ibid.  *  Ibid. 


SECTION   II. 

ABERRATIONS  IN  ERUPTION  OF  THE  TEETH. 


CHAPTER  III. 

DENTITION:  ITS  PROGRESS,  VARIATIONS,  AND 
ATTENDANT  DISORDERS. 

The  process  of  teething,  eruption,  or  dentition  comprises  that 
series  of  vital  operations  which  causes  the  teeth  to  leave  their  crypts 
in  the  maxillse,  to  pierce 

the  gum,  and  to  take  their  Fig.  34 

places  in  the  dental  arches. 
It  is  a  continuation  of  the 
process  of  dental  develop- 
ment, and  is  accompanied 
and  succeeded  by  root,  al- 
veolar, and  maxillary  de- 
velopments, which  are  also 
to  be  considered  in  con- 
nection with  it. 

Physiologically,  denti- 
tion is  divided  into  (1) 
the  first  dentition,  or  that 
of  the  temporary  teeth, 
and  (2)  the  second  denti- 
tion, or  that  of  the  per- 
manent teeth. 

Examination  of  Fig.  34 
will  show  the  state  of 
tooth  development  at  a 
period  shortly  after  birth 

(a  central  incisor  being  under  consideration).  The  crj^pt  is  roofed 
over  at  birth  by  a  membranous  structure.  During  the  period  from 
then  to  perhaps  six  months  after  birth^  about  one-third  of  the  root 

(63) 


Developing  tooth  at  birth:  A,  developing  bone; 
B,  tissue  reflected  from  follicular  wall  and  forming 
alveolar  periosteum;  C,  folUcular  wall;  D,  vessels 
and  nerves;    E,  epithelium  of  gum. 


64 


DENTITION 


will  have  been  formed  and  the  tooth  crown  and  part  of  the  root  will 
have  extruded  from  the  crypt  and  be  merely  covered  by  the  soft  tissues. 
(See  Fig.  36.)  The  root  end  is  widely  open  (incomplete)  and  the  margins 
are  thin  and  sharp.  The  vascular  pulp  and  follicular  tissue  occupies  the 
space  between  the  root  and  the  bone,  and  fills  the  interior  of  the  root. 


Fig.  35 


k—A~-A-~--Ah- 


22  months  after  birth 
18  months  after  birth  - 


12  months  after  birth 
6  months  after  birth 


40th  week  (birth)  Jp-—- ; 
30th  week  embryo .....      .„. 

18th  week  >^mhr^m    I    p   ^m     l,-h..rMaM   .%.„,^,i^      %.,Mi\i:.,IMIiI        \,  ..la^S^Sa^i/ 


17th  week  embryo  ■ 


'1  -r,aiE..aaaa™By        iiaiSs 


Fig.  36 


Calcification  of  the  deciduous  teeth.      (Peirce.') 

Meanwhile  the  crown  cusp  will  have  advanced  from  the  situation 
shown  in  Fig.  34  to  a  point  just  beneath  the  mucous  membrane, 
which  is  pressed  up  and  stretched  over  the  advancing  tooth  crown, 
presenting  to  oral  view  a  tumefied  condition  more  or  less  correspond- 
ing to  the  form  of  the  crown. 
This  is  nicely  shown  in  Fig.  36, 
.4  and  B. 

These  anatomical  data  serve 
for  the  consideration  of  the 
causes  and  process  of  eruption. 
Causes  of  Eruption. — It  is 
evident  that  there  are  forces 
which  can  bring  about  the 
elevation  of  a  tooth  crown  from 
its  bed  in  the  crypt  to  its  posi- 
tion in  the  mouth. 

The  consideration  of  these  has 
led  to  the  development  of  the 
following  rational  theories,  as 
well  as  others  now  obsolete: 
1.  That  crown  elevation  is  due  to  the  lengthening  of  the  root — 
i.  e.,  as  root  tissue  is  formed  by  the  pulp  and  follicle  wall  Ijang  beneath 
and  to  the  side  of  its  edges,  the  tooth  is  mechanically  pushed  up,  the 
tissues  lying  above  it  are  stimulated  and  absorbed,  and  as  more  root 
is  formed,  a  further  extrusion  occurs.    It  i§  to  b^  noted  that  the  root 


Lines  of  incision  in  lancing:  A,  A,  over 
the  molars;  B,  B,  over  the  cuspids  and  in- 
cisors before  eruption;  C,  C,  C,  over  the 
molars  and  cuspids  after  partial  eruption. 


DENTITION 


65 


end  occupies  the  same  level,  at  all  stages  of  eruption,  in  the  devel- 
oping jaw  that  was  occupied  by  the  cervical  edge  of  the  crown 
(Fig.  37).  As  no  two  bodies  may  occupy  the  same  space  at  the  same 
time,  the  root-forming  pulp  and  follicle  wall  push  the  tooth  up,  to 
gain  room  for  more  root  formation.  The  mild  continued  pressure 
is  quite  competent  to  do  this.  The  pressure  of  the  soft  tissues  against 
the  root  end  is  explained  by  Constant  to  be  derived  from  the  normal 
blood  pressure.^  That  such  an  internal  pressure  exists  is  shown  by 
the  extrusion  of  ordinarih^  confined  parts  when  released  from  the 
accustomed  pressure.  A  simple  accident  demonstrated  this  to  the 
editor.  While  excavating  with  a  large  bur,  the  softened  dentin  about 
a  decayed  pulp  chamber,  the  cementum  was  widely  removed  from 
the  pericemental  tissue  beneath,  which  latter  fortunately  remained 
unbroken.    It  immediatelj'  protruded  into  the  perforation.    Constant 

Fig.  37 


Diagram   showing  the  upward  movement  of  the  crown    during   eruption    and  root 
development.     (Constant.) 


also  cites  the  extrusion  of  a  tooth  in  pericementitis  as  an  evidence 
of  the  influence  of  the  blood  pressure.  Another  evidence  is  the 
occasional  rapid  advance  of  a  tooth  after  lancing  of  the  gum. 

2.  The  process  of  tooth  development  is  a  vital  process,  and  that  of 
eruption  has  been  held  also  to  be.  (Tomes.)  That  cells  concerned 
in  development  seem  to  have  a  predestined  end  or  function  cannot  be 
denied;  at  the  same  time,  throughout  dental  development,  defined 
resistances  to  opposing  forces  seem  to  play  a  part  in  the  moulding  of 
the  soft  and  hard  tissues — e.  g.,  the  depression  of  the  enamel  organ 
by  the  papilla. 

3.  Peirce^  holds  that  the  impact  of  blows  upon  the  jaws  causes  the 
tooth  to  rise  toward  the  gum.  He  explains  the  eruption  of  crowns 
without  roots  upon  this  theory. 


'  Inteigiational  Dental  Journal,  June,  1903. 
5 


American  System  of  Dentistry. 


66  DENTITION 

4.  Tomes  explains  the  eruption  of  teeth,  after  development  of  the 
root,  upon  the  theory  that  the  closing  in  of  the  alveolar  process  or 
contraction  of  the  alveolus  upon  the  pericementum  (follicle  wall) 
causes  the  lifting  up  of  the  tooth.  That  such  a  closure  occurs  about 
the  extruding  roots  of  teeth  left  after  the  breaking  away  of  the  crowns, 
is  shown  by  examination  of  the  sockets  of  such  roots.  An  abnormally 
shallow  alveolus  closed  by  deposition  of  bone  at  its  apex  will  be  found 
in  cases  of  small  apical  portions  of  roots  so  extruded. 

It  is  well  known  that  mild  hyperemia  is  produced  in  pericementi 
which  do  not  receive  a  normal  resistance,  which  would  account  for 
both  the  elevation  and  bone  deposition  on  the  ground  of  blood 
pressure.    (See  Arterial  Hyperemia.) 

Fig.  38 


Pulp  cavities  of  the  superior  first  bicuspid,  from  the  seventh  to  the  twelfth  year. 

(BroomeU.i) 

The  Process  of  Dentition. — At  varying  ages,  according  to  the 
state  of  tooth  development,  the  formed  crown  of  the  tooth  advances 
and  presses  upon  the  follicle  wall  overlying  it;  this  is  irritated,  and 
giant  cells  are  developed,  which  by  resorption  remove  this  as  well 
as  the  upper  edge  of  the  wall  of  the  crypt.  In  the  anterior  teeth  this 
resorption  occurs  on  the  outer  incisal  half  of  the  crypt  wall,  the  inner 
side  remaining  intact  (Broomell).  The  mucous  membrane  is  pushed 
up  and  moulded  over  the  crown,  thereby  causing  a  tumefaction. 

The  mucous  membrane,  at  first  normal  in  color,  becomes  slightly 
hyperemic,  and  then  may  change  to  an  ischemic  condition  and  whiten, 
owing  to  the  removal  of  the  blood  by  the  pressure  of  the  underlying 
crown.  Resorption  from  beneath  causes  a  break  in  the  continuity  of 
the  mucous  membrane,  and  the  crown  tip  erupts  into  the  mouth 
(Fig.  36,  C). 

The  rate  of  resorption  and  crown  advance  are  equalized  in  perfectly 
normal  dentition.     (See  cause  of  pathological  dentition  page  70.) 

»  Anatomy  and  Histology  of  the  Mouth  and  Teeth. 


DENTITION 


67 


The  crown  rises  from  the  gum,  is  directed  by  the  tongue  and  Hp  or 
cheek,  and,  finally,  meets  its  antagonists  of  the  opposite  jaw.  The 
interlocking  of  cusps  and  meeting  of  occlusal  surfaces  limit  further 
movement  of  position. 

Meanwhile  root  development  proceeds,  and  as  it  occurs  the  alveolar 
process  is  built  about  the  pericementum,  which  consists  of  the  follicle 
wall  drawn  up.  By  this  means  the  roots  are  firmly  implanted. 
The  further  development  of 

the  root  proceeds  until  com-  ■^^°-  ^^ 

plete,  and  so  remains  until 
normal  resorption  of  the 
temporary  roots  occurs,  and 
for  life  in  the  permanent 
teeth.  The  scheme  of  root 
development  and  addition  is 
shown  in  Figs.  38  and  39. 

The  state  of  formation 
of  the  roots  of  temporary 
teeth  at  any  given  age  may 
be  judged  by  the  table  of 
averages  shown  by  Peirce 
in  Fig.  35.  Being  but  aver- 
ages, allowance  for  precocity 
or  delay  must  be  made. 

Apart  from  the  presence 
of  the  temporary  teeth,  the 
process  of  eruption  is  iden- 
tical in  both  sets  of  teeth. 
(Fig.  40.) 

Periods  of  Eruption. — 
As  a  general  rule,  the  erup- 
tion of  the  deciduous  teeth 
may  be  said  to  begin  about 
the  seventh  month  after 
birth,    and     is    completed 

somewhere  about  the  thirtieth  month.  Variations  occur;  some  chil- 
dren may  be  born  with  teeth  erupted;  again,  the  initiation  of  the 
process  may  not  occur  until  the  twelfth  month,  or  even  later. 

The  incisor  teeth  are  usually  erupted  in  pairs,  the  molars  and 
cuspids  making  their  appearance  in  fours,  the  first  molars  in  one 
group,  the  cuspids  in  another,  and  the  second  molars  in  a  third  group. 
The  several  groups  require  different  lengths  of  time  to  complete  their 
eruption,  the  time  occupied  in  the  eruption  of  the  first  molars  being 


Diagram  illustrating  root  development  and 
condition  of  an  incomplete  root:  E,  enamel; 
D,  dentin;  P,  pulp  containing  odontoblasts, 
OB;  AP,  alveolar  process;  B,  bone;  C,  cemen- 
tum;  P',  periosteum  of  bone  continuous  with 
the  pericementum;  PER,  pericementum  con- 
taining cementoblasts,  CB;  A,  V,  N,  arteries, 
veins,  and  nerves. 


68 


DENTITION 


longer  than  that  required  for  the  eruption  of  the  other  groups. 
Between  the  appearance  of  additional  groups  of  the  teeth  an  interval 
elapses,  no  doubt  a  physiological  provision,  for,  as  will  be  shown 
later,  the  process  of  dentition  is  usually  accompanied  by  evidences  of 
more  or  less  local  disturbance,  frequently  by  disturbances  through- 
out the  intestinal  tract,  and  even  reflex  disorders  of  the  central 
nervous  system  occur.  It  is  believed,  therefore,  that  the  period 
which  elapses  between  the  eruption  of  the  dental  groups  permits 
the  organism  to  recover  from  the  effects  of  previous  disturbance 
before  the  new  source  of  irritation  appears. 

Fig.  40 


View  of  the  upper  jaw  of  a  child,  aged  about  six  and  one-half  years.  The  anterior 
teeth  are  slightly  separated  by  the  partially  developed  permanent  teeth,  lying  behind 
or  posterior  to  them,  pushing  forward  to  occupy  a  more  anterior  position.  The  equal 
height  which  the  crowns  of  the  deciduous  teeth  originally  occupied  is  also  being  dis- 
turbed by  the  advancing  permanent  teeth.     (Peirce.) 


Table.i 


Group  1 

Lower  central  in- 

Tirne of  eruption, 

Duration  of  eruption, 

Interval,  2  to  3  months. 

cisors 

7  months 

1  to  10  days 

Group  2 

Upper  central  and 

Time  of  eruption, 

Duration  of  eruption. 

Interval,  2  months. 

lateral  incisors 

9  months 

4  to  6  weeks 

Group  .3 

Lower  lateral  in- 
cisors 

Time  of  eruption, 
12  months 

Group  4 

First  molars 

Time  of  eruption, 
14  months 

Duration  of  eruption, 
1  to  2  months 

Interval,  4  to  5  months. 

Group  5 

Cuspids 

Time  of  eruption, 
18  months 

Duration  of  eruption, 
2  to  3  months 

Interval,  3  to  5  months. 

Group  6 

Second  molars 

Time  of  eruption. 

Duration  of  eruption, 

26  months 

3  to  5  months 

I  Coleman's^Dental  Surgery  (Stellwageu). 


PATHOLOGICAL  FIRST  DENTITION  69 

In  the  above  table  it  will  be  noted  that  the  time  of  eruption  of 
the  lower  lateral  incisors  is  later  than  that  of  the  eruption  of  the  upper 
lateral  incisors.  The  reverse  course  is  frequently  observed;  indeed, 
it  has  usually  been  accepted  as  the  rule  of  precedence  in  the  United 
States.  All  tables,  as  to  periods  of  eruption,  give  but  the  approxi- 
mate times;  while  variations  are  extremely  common.  The  ages 
given  in  this  table  are  those  at  about  which  the  several  teeth  may 
be  expected  to  make  their  appearance.  Stellwagen  (the  American 
editor  of  Coleman),  in  commenting  upon  this  table,  states  that  the 
periods  of  eruption  in  this  country  are  from  one-seventh  or  more, 
earlier  than  the  dates  given.  He  suggests  that  the  difference  in 
food  habit  may  account  for  the  differences  in  time. 

Accompanying  the  development  and  eruption  of  the  teeth,  occur 
developmental  changes  in  all  of  the  glandular  appendages  of  the 
alimentary  canal ;  probably  the  alterations  in  their  structure,  and  no 
doubt  in  their  physiological  chemistry,  are  accompanied  by  dental 
provision  for  the  mechanical  subdivision  of  foods  of  postinfantile 
character. 

Symptoms  of  Eruption. — Slight  local  disturbances  are  so  com- 
mon in  even  so-called  normal  first  dentition  as  to  be  accepted  as 
physiological.  The  resorption  of  soft  tissue  around  the  tip  of  the 
crown  of  the  tooth  implies  a  condition  of  mild  non-septic  inflamma- 
tion at  that  point.  In  more  marked  cases  there  is  evidence  of  some 
irritation  cognizable  to  the  infant;  the  gum  is  of  a  somewhat  deeper 
color  and  its  temperature  is  elevated.  Relief  is  afforded  by  pressure, 
which  temporarily  reduces  the  hyperemia,  and  the  child  is  pleased 
to  have  its  gums  rubbed,  to  bite  upon  its  own  or  the  nurse's  fingers, 
upon  rings  or  other  objects.  Still  more  marked  is  the  soothing  effect 
of  biting  upon  cold  substances,  such  as  ice,  which,  in  addition  to 
mechanically  lessening  the  blood  supply,  causes  contraction  of  the 
dilated  vessels. 

Slight  reflex  disturbances  are  evidenced  by  the  stimulation  of  the 
salivary  glands,  which  produces  an  increased  flow  of  saliva. 

Reflex  disturbances  of  more  severe  character  occur  in  pathological 
dentition,  to  be  considered  later. 


PATHOLOGICAL   FIRST   DENTITION. 

The  local  disturbances  may  be  exaggerated  beyond  that  degree 
accepted  as  physiological,  and  may  be  accompanied  by  nervous, 
alimentary,  pulmonary,  or  cutaneous  disturbances.  This  is  patho- 
logical dentition,  and  may  be  of  several  grades  of  severity. 


70  DENTITION 

Causes  and  Pathology. — The  primary  cause  of  pathological  dentition 
may  be  stated  as  an  inequality  in  the  rate  of  gum  resorption  and 
crown  advance.  The  advancing  crown  pressing  upon  the  gum  tissue 
causes  irritation;  the  mild  aseptic  inflammation  resulting,  instead  of 
remaining  at  a  pomt  favoring  the  development  of  giant  cells  and 
resorption,  passes  the  physiological  point  and  causes  a  disturbance 
of  function.  Inflammation,  simple  or  even  infective,  may  occur  in 
the  area. 

Swelling  of  the  gum  occurs,  which,  being  distributed  in  all  direc- 
tions, presses  upon  the  crown,  depressing  it  upon  the  pulp  and  follicle 
wall  beneath  the  sharp  root  margms;  at  the  same  time  the  blood 
pressure  of  the  tissues  tends  to  press  the  tooth  upward.  The  simple 
lack  of  i-esorption  of  the  gum  would  be  almost  equally  effective  in 
preventing  eruption  and  this  may  be  an  accompaniment  of  the 
inflammation  (Impaired  function,  see  page  40). 

The  sharp  edges  of  the  root  must  irritate  the  sensitive  and  delicate 
pulp  tissue,  which  becomes  inflamed  and  swollen,  and  still  more 
strongly  urges  the  tooth  upward.  Two  sources  of  disturbance  now 
are  possible:  (1)  the  irritated  gum  tissue  and  (2)  the  irritated  pulp. 
Though  the  pulp  is  more  likely  to  produce  the  reflex  distm-bance,  a 
gum  inflammation,  if  intense,  is  often  capable  of  producing  even 
prostrating  sjmptoms.  (See  Pathological  Dentition  of  Third  Molars.) 
Through  the  intimate  sympathetic  relations  of  the  fifth  cranial  nerve, 
supplied  to  the  pulp,  with  the  sixth,  seventh,  ninth,  and  tenth  cranial 
nerves  in  and  about  the  floor  of  the  fourth  ventricle  of  the  brain, 
salivary,  muscular,  nervous,  alimentary,  and  pulmonary  disturbances 
become  possible.  Any  systemic  disturbance — e.  g.,  measles,  general 
debility,  or  lesser  disturbance,  etc. — ^which  lowers  the  general  nutri- 
tive function  also  in  the  parts  associated  with  the  teeth,  may  favor 
the  production  of  local  pathological  phenomena.  Again,  systemic 
disturbance  readily  produces  a  hyperesthesia  of  the  nervous  system, 
favoring  the  production  of  nervous  phenomena. 

Pathological  dentition  may  occur  in  the  absence  of  an  evident 
hyperemic  gum  tissue.  The  tissue  may  be  white,  showing  ischemia 
from  pressure,  a  binding  down  of  the  root  end  upon  the  pulp  being 
proved  by  the  subsidence  of  symptoms  after  lancing,  and  sometimes 
by  the  rapid,  partial  eruption  of  the  tooth  immediately  after  lancing. 

Again,  pathological  phenomena  have  been  noted  where  no  super- 
ficial local  disturbance  was  evident.  In  these  cases  the  deeper  tissues 
may  exert  a  restraining  influence  upon  the  crown,  but  the  swelling 
is  just  as  probable. 

It  is  to  be  understood  that  the  nervous  and  digestive  systems  of 
the  child  are  in  a  developmental  condition,  and  therefore  in  unstable 


PATHOLOGICAL  FIRST  DENTITION  71 

physiological  equilibrium,  so  that  any  added  physiological  work,  such 
as  unusual  growth  or  dentition,  may  be  more  than  the  organism 
can  endure  without  a  definite  loss  of  general  vital  potential.  This 
may  be  further  complicated  by  hereditary  defects  of  tissue,  such  as 
neurotic,  degenerative,  or  syphilitic  taint,  or  conditions  of  hygiene  or 
feeding  tending  to  lower  the  health  standard. 

Ottofy  offers  the  following  report,  by  the  Bureau  of  Health  of 
Manila,  of  3250  deaths  before  twelve  months  of  age: 

Before  completing  one  month 647 

During  second  and  third  months 302 

Various  causes  not  dental 959 

Four  to  twelve  months  due  to  convulsions  and  eclampsia  .      .      .  1342 

Total 3250 

Showing  a  large  number  of  deaths  due  to  causes  in  which  dentition 
may  have  been  a  determining  or  complicating  factor. 

Dr.  William  P.  Spratley,  medical  superintendent  of  an  institution 
for  epileptics,  states  it  as  his  opinion  that  pathological  first  and  second 
dentition  is  a  determining  cause  of  epilepsy  in  children  having 
neuropathic  taint  in  that  direction.^ 

Symptoms. — ^The  symptoms  of  pathological  dentition  are  both  local 
and  general. 

Local  Symptoms. — The  local  symptoms  are  usually  those  of  inflam- 
mation, red  and  swollen  gum  tissues  at  times  assuming  a  dusky  hue. 
The  gums  may  be  white,  and  often  glistening,  indicating  their  tense 
stretching  over  the  crowns.  In  the  gum  over  the  erupting  tooth 
there  may  exist  a  vesicular  enlargement  containing  fluid.^  Evidence 
of  local  irritability  is  given  by  the  fact  that  the  child  resists  the 
touching  of  the  gums,  seizes  the  breast  or  bottle  nipple,  and  imme- 
diately releases  it. 

The  readiness  with  which  the  child  will  take  cold  substances,  ice 
or  iced  water,  is  notable  and  self-explainable.  Alternate,  excessive 
flow  of  saliva  and  oral  dryness  are  present. 

In  the  more  marked  cases  of  local  disturbance,  evidences  of  bacterial 
infection  of  the  mucous  membrane  of  the  mouth  may  make  their 
appearance,  such  as  ulcerative  stomatitis.  While,  as  a  rule,  the 
breaking  down  and  ulceration  of  the  tissue  are  confined  to  the  parts 
overlying  the  erupting  teeth,  a  general  stomatitis  or  widely  scattered 
patches  of  ulceration  may  make  their  appearance. 

General  Symptoms. — ^The  general  symptoms  may  be  differ- 
entiated into  mild  and  severe. 

The  mild  symptoms  are  such  as  are  attendant  upon  severe  and 
painful  inflammations  about  the  face  at  almost  any  age;  thus  anorexia, 

1  Dental  Cosmos,  1905.  ^  Tomes,  System  of  DentalyOurgery. 


72  DENTITION 

fretfulness,  anger,  restlessness,  sleeplessness,  thirst,  mild  fever,  and 
evident  desire  for  the  upright  position  occur.  The  pain  is  at  times 
paroxysmal,  but  may  become  continuous. 

These  symptoms  subside  upon  the  eruption  of  the  tooth  or  lancing, 
though  erupting  cuspids,  bound  by  a  ring  of  tense  gum  tissue  or  by 
adjoining  teeth,  may  continue  the  irritation  even  when  apparently 
erupted  (Fig.  36,  C).  Again,  the  cuspids  may  be  caught  between 
the  lateral  and  first  molar.  The  more  severe  general  symptoms  are 
such  as  are  brought  about  by  reflex  neuroses. 

The  roots  of  the  fifth  cranial  nerves  supplied  to  the  teeth  are  in 
intimate  relation  with  the  roots  of  the  sixth,  se^'enth,  ninth,  and  tenth 
cranial  nerves  in  the  floor  of  the  fourth  ventricle,  as  well  as  with 
other  cranial  nerves.  It  may  be  argued  upon  a  priori  grounds  that 
irritation  of  the  peripheral  ends  of  the  fifth  in  the  pulp  tissue  may 
therefore  readily  produce  neurotic  results  in  the  brain,  salivary 
glands,  skin,  lungs,  or  larynx,  intestinal  canal,  or  muscles  of  the  face 
or  extremities. 

Taking  the  intestinal  canal  as  the  most  complicated  example,  we 
find  the  following  data:  The  stomach  and  intestines  are  under  the 
influence  of  the  pneumogastric  nerve,  which  sends  to  its  muscular 
coats  both  stimulant  and  inhibitory  fibers.  Likewise  it  sends  vaso- 
motor fibers  to  the  intestines,  division  of  which  leads  to  inhibition 
of  the  muscular  fibers  of  the  vessels  and  leads  to  vasodilatation 
and  a  great  increase  of  very  watery  succus  entericus.^ 

Intestinal  Disturbances. — That  intestinal  disturbances  may  arise 
independently  of  teething  is  self-evident,  but  as  they  are  most  liable 
to  so  occur  during  the  very  period  during  which  teething  may  be 
supposed  to  act  as  a  primary  cause  of  intestinal  troubles;  hence 
differentiation  becomes  important. 

As  a  rule,  intestinal  disturbances  arise  from  improper  feeding,  the 
food  acting  as  an  indigestible  irritant  to  the  stomach  and  intestines. 
Even  an  excessive  quantity  of  good  breast  or  bottle  milk  may,  if  not 
regurgitated,  act  as  an  intestinal  irritant.  The  milk  of  an  excited, 
exhausted,  or  debauched  nurse  may  also  act  deleteriously.  Fermen- 
tation due  to  bacteria  ensues,  and  diarrhea  and  colic  are  a  natural 
result.  Naturally  micleanly  conditions  concerning  the  milk,  bottle, 
nipple,  teething  ring,  etc.,  introduce  an  infective  element  which  may 
be  sufF.cient  to  this  result. 

Musser^  attributes  these  cases  to  development  of  the  Bacillus  coli 
communis  and  Bacterium  lactis  aeriformis  existing  harmlessly  in  the 
normal  intestine,  but  developing  under  the  abnormal  conditions. 

1  Halliburton,  Kirke's  Physiology,  1896,  p.  684.  2  Medical  Diagnosis. 


PATHOLOGICAL  FIRST  DENTITION  73 

This  occurring  in  warm  weather,  when  the  child  suffers  from 
uitense  heat,  has  a  xery  debihtating  if  not  fatal  result,  and  may  dis- 
turb all  nutrition,  including  dentition,  which,  becoming  pathological, 
adds  its  effects.  In  the  so-called  second  summer  the  child  often  erupts 
cuspids  or  molars. 

A  similar  train  of  circumstances  may  be  caused  by  teething. 
Peripheral  irritation  of  terminals  of  the  fifth  nerve  in  the  pulp  may, 
through  the  tenth  nerve,  cause  a  reflex  vasomotor  dilatation  in  the 
walls  of  the  intestines — i.  e.,  hj^eremia  and  excess  secretion,  a  condi- 
tion which  favors  bacterial  mvasion.  Intestinal  digestion  is  dis- 
ordered, the  vital  resistance  lowered,  and  an  infection  ordinaril}' 
resisted  occurs,  as  when  the  intestine  is  primarily  disordered. 

Diarrhea  may  follow.  In  either  case  alimentation  is  interfered 
with  and  the  general  nutrition  suffers.  The  child  is  debilitated  by 
lack  of  nutrition;  moreover,  toxic  substances  are  generated  in  the 
intestine,  which  cause  a  toxemia,  to  which  many  of  the  general 
symptoms  may  be  attributed,  such  as  fever,  meningitis,  stupor, 
coma,  and  death.  The  general  debility  also  further  interferes  with 
the  process  of  dentition.    Thus  there  may  be  a  vicious  circle. 

Diagnosis. — A  diarrhea  due  to  improper  feeding  would  not  be 
preceded  by  symptoms  of  pathological  dentition,  or  may  not  occur 
at  a  time  proper  for  dentition;  would  have  a  history  of  improper 
feeding,  and  possibly  of  unhygienic  conditions,  such  as  unsterilized 
milk  or  milk  bottles,  filthy  surroundings,  etc.  There  is  a  catarrhal 
diarrhea  accompanied  by  vomiting  and  constant  acid,  watery  stools. 
The  stools  may  have  a  chopped-spinach  character.  There  is  colic 
due  to  collections  of  gas. 

Such  an  infective  diarrhea  may  readily  follow  the  reflex  and 
debilitating  effects  of  pathological  dentition,  as  shown  above. 

White^  has  noted  that  a  choleraic  diarrhea  may  accompany  and  be 
a  sign  of  pathological  dentition.  Barrett^  states  that  a  diarrhea  due 
to  dentition  will  probably  be  followed  by  constipation, 

A  symptomatic  diarrhea  will,  as  a  rule,  be  accompanied  by  signs 
of  pathological  dentition  at  points  in  the  jaws,  at  which  teeth  should 
be  in  process  of  eruption. 

Nervous  Disturbances. — Disorders  referable  to  the  central 
nervous  system  are  the  most  alarming,  and  are  those  indicating  the 
higher  grades  of  severity  of  irritation. 

The  milder  forms  of  these  are  faint  muscular  twitchings  and 
evidences  of  slight  cerebral  disturbance. 

Either  of  these  may  be  the  result  of  poisons  absorbed  from  the 

'  American  System  of  Dentistry.  2  Oral  Pathology  and  Practice. 


74  DENTITION 

alimentary  canal  during  the  course  of  intestinal  fermentation,  but  as 
cases  of  even  convulsions  have  occurred  without  other  cause  than 
teething  apparent,  and  been  relieved  by  lancing  alone,  the  possibility 
of  direct  connection  between  teething  and  central  nervous  disturbance 
must  be  admitted. 

A  distressing  symptom,  not  easy  to  elicit  on  account  of  the  age  of 
the  patient,  is  headache.  The  child  is  sleepless,  and  cries  without 
apparent  cause;  it  becomes  quiet,  partially  from  exhaustion,  and 
after  a  period  again  commences  sobbing.  The  indication  of  central 
disturbance  may  at  times  be  noted  in  the  contracted  pupils  of  the 
eyes  and  in  throbbing  arteries.  The  usual  treatment,  the  adminis- 
tration of  chloral  hydrate  and  potassium  bromide,  with  cold  appli- 
cations to  the  head,  furnishes  relief  which  is  frequently  not  complete 
without  attention  to  the  dental  organs. 

In  the  more  severe  and  dangerous  cases,  the  evidences  of  disorder 
of  the  central  nervous  system  become  unmistakable.  These  appear 
as  clonic  convulsions  or  symptomatic  eclampsia.  While  it  is  probable 
in  many  cases  that  reflex  irritation  from  the  process  of  dentition  in 
itself  is  but  a  secondary  cause  of  convulsions,  yet  evidence  is  sufficient 
to  warrant  its  being  regarded  as  a  determining  factor.  In  very  many 
cases  teething  convulsions  appear  to  indicate  a  neurotic  family  taint, 
and  eclampsia  may  attend  many  disorders  in  children  of  this  type, 
notably  the  mechanical  and  chemical  irritation  induced  by  the 
presence  of  large  masses  of  indigestible  food  in  the  intestines.  It 
would  therefore  seem  a  result  of  reflex  action,  the  source  of  periph- 
eral irritation  not  being  of  prime  importance. 

So-called  teething  convulsions  occur  usually  at  a  time  when  several 
teeth  are  in  process  of  eruption.  The  onset  of  the  convulsion  is 
rarely,  although  apparently  often,  sudden.  If  the  child  be  closely 
observed,  it  is  noted  that  a  period  of  cerebral  disturbance — fretful 
crying,  evidences  of  headache,  sleeplessness,  etc. — is  followed  by  a 
period  of  dulness  and  somnolence,  or  the  child  may  lie  with  eyes 
half  open.  Twitching  of  one  or  more  groups  of  muscles  may  be 
observed;  the  orbicularis  oris  and  other  muscles  of  the  lips,  and  the 
muscles  of  the  eye,  notably  the  superior  and  internal  recti,  may 
contract  spasmodicafly.  A  common  muscular  spasm  ushering  in  con- 
vulsions, is  that  of  the  abductor  muscles  of  the  thumb;  the  thumbs 
are  drawn  toward  the  palms  of  the  hands.  The  abductor  muscles  of 
the  feet  contracting,  the  feet  are  drawn  inward.  This  period  may 
be  ushered  in  by  a  sharp  cry,  the  eyes  roll  upward  with  the  lids 
half  open,  and  consciousness  is  lost.  The  symptoms  may  disappear, 
the  child  awakening  dazed  and  fretful;  or  it  may  sink  into  sleep. 
Unless  the  source  of  irritation  be  removed,  or  active  therapeutic 


PATHOLOGICAL  FIRST  DENTITION  75 

measures  be  instituted,  the  eclampsia  may  return  and  in  severe 
cases  be  the  precursor  of  death. 

Infantile  paralysis  of  a  group  of  muscles,  or  even  a  single  muscle, 
has  been  recorded,  lasting  from  a  few  days  to  months,  appearing  with 
dentition  and  disappearing  after  it.  In  some  cases  it  persists  for 
life.^    Strabismus  (sixth  nerve),  if  produced,  may  also  persist. 

Skin  Disorders. — It  is  so  common  as  to  be  almost  termed  the  rule, 
to  find  that  when  there  are  intestinal  symptoms  there  are  eruptions 
observable  on  the  skin.  The  mildest  form  of  these  is  an  herpetic 
eruption  about  the  mouth;  in  other  cases  papular  and  vesicular 
eruptions  are  observed  upon  the  skin  of  the  body  and  limbs. 

Occurring  within  the  mouth,  infection  may  be  added  and  ulcerative 
stomatitis  may  occur  upon  the  gums,  tongue,  lips,  or  inside  of  the 
cheek. 

Pulmonary  Symptoms. — Pulmonary  irritation  may  be  expressed  in 
laryngeal  cough  attending  the  eruption  of  teeth,  and  disappearing 
thereafter. 

Treatment  of  Pathological  First  Dentition. — This  may  be  divided  into 
prophylactic  and  remedial.  The  prophylactic  measures  include  care 
as  to  pasteurization  of  milk  or  modified  milk  diet,  sterilization  of 
bottles,  bottle  nipples  and  rings,  the  prevention  of  the  introduction  of 
unclean  fingers  into  the  mouth  of  the  child,  and  the  antiseptic  care 
of  its  mouth  by  frequent  washings  with  a  saturated  solution  of  boric 
acid  in  water.  This  last  may  be  applied  to  the  mouth  on  a  soft,  linen 
rag  wrapped  on  the  forefinger.  These  measures,  together  with  the 
proper  feeding,  ventilation,  and  care  as  to  clothing,  which  should 
give  comfort  and  not  be  in  any  way  irritating,  tend  to  prevent  intes- 
tinal fermentation  and  to  reduce  the  general  irritability  of  the  infant. 

Remedial  Measures. — To  reduce  local  hyperemia  of  the  gum 
above  an  erupting  tooth,  a  common  domestic  measure  is  valuable,viz., 
a  small  block  of  ice  is  placed  in  a  corner  of  a  clean  napkin,  and  con- 
fined in  place  by  a  thread;  the  infant  places  it  in  its  mouth  at  pleasure 
if  old  enough,  or  the  nurse  permits  the  child  to  bite  upon  it.  The 
mechanical  effect  of  biting  upon  a  hard  substance  has  added  to  it  a 
degree  of  cold  which  lessens  the  local  vascular  engorgement. 

Any  severe  local  irritation  about  erupting  teeth  should  be  relieved 
by  thorough  lancing  of  the  gum.  It  is  irrational  that  the  child  should 
be  permitted  to  suffer  from  local  irritation  which  may  develop  into 
more  serious  complications. 

This  operation  is  performed  by  dividing  the  gum  lineally  over  the 
incisors  and  cuspids  before  eruption,  crucially  over  the  cuspids  after 

^  White,  American  System  of  Dentistry. 


76  DENTITION 

eruption  of  the  cusps  only,  crucially  over  the  upper  first  molar,  and 
with  an  X-incisor  over  the  upper  second  and  lower  first  and  second 
molars  (Fig.  36). 

For  severe  cases  Flagg  advised  the  removal  of  a  block  of  gum 
from  over  a  molar.  A  cut  is  made  parallel  with  the  lingual  side  of 
the  crown,  a  second  parallel  with  the  buccal  side,  a  third  parallel 
with  the  mesial  side.  A  tenaculum  is  thrust  into  the  block  of  gum, 
which  is  drawn  tense,  and  then  divided  at  the  distal  portion,  prefier- 
ably  with  a  pair  of  curved  gum  scissors.  Lacking  these  latter,  the 
bistoury  may  be  used. 

The  cut  over  the  upper  incisors  should,  if  possible,  be  made  a 
little  to  the  outside  of  the  cutting  edge,  that  for  the  lower  to  the 
inside,  in  order  that  their  crowns  may  take  a  proper  direction  toward 
occlusion. 

The  instrument  to  be  used  is  a  sharp-pointed  bistoury,  as  it 
penetrates  well  and  permits  a  free  draw  cut.  It  is  to  be  wrapped 
with  tape  or  a  strip  of  linen  cloth  until  only  one-quarter  of  an  inch  of 
the  point  is  exposed.  This  precaution  prevents  accidental  wounds. 
The  child  must  be  securely  held  by  an  assistant,  the  least  sympathetic 
available. 

Flagg's  method  was  to  place  the  child  upon  its  back  across  the 
lap  of  the  assistant,  who,  in  one  position,  places  his  left  hand  over  the 
child's  eyes,  securing  the  head;  his  right  hand  secures  the  hands  upon 
the  abdomen,  while  the  legs  are  held  against  his  body  by  the  right 
arm.  The  position  may  be  exactly  reversed.  The  feet  should  be 
placed  toward  the  light  for  the  upper  jaw,  the  reverse  for  the  lower 
jaw.  In  another  position  the  child  sits  upon  one  thigh  of  the  assist- 
ant, the  back  of  the  head  resting  upon  the  chest,  and  the  hand  of  that 
side  (usually  the  right)  pressed  over  the  child's  eyes  to  hold  the  head 
firmly.  The  other  hand  and  forearm  hold  the  child's  hands  and  legs 
firmly. 

The  operator  encloses  the  gum  about  the  part  to  be  cut  with  the 
thumb  and  forefinger  of  the  left  hand,  so  that  the  bistoury  cannot 
slip  and  cut  lip,  cheek,  or  tongue.  Incision  over  the  erupting  tooth 
should  be  made  until  the  knife-blade  is  felt  to  touch  the  enamel 
surface.  The  operation  of  scarifying  the  gums,  making  merely  a  few 
scratches  to  relieve  engorged  vessels,  is  but  temporizing  with  the 
condition;  the  cut  should  be  of  sufficient  extent  to  entirely  remove 
tension  from  above  the  tooth.  The  little  finger  of  the  right  hand  may 
rest  upon  the  chin  of  the  child  as  an  additional  guard. 

If  the  child  bite,  a  cork  with  a  string  attached  for  safety  may  be 
used  as  a  prop.    Asepsis,  as  in  other  oral  surgery,  should  be  observed. 

More  or  less  bleeeding  follows  upon  the  operation,  and,  as  a  rule, 


PATHOLOGICAL  FIRST  DENTITION  77 

ceases  spontaneously.  A  short  period  of  bleeding  is  desirable,  so  that 
vascular  engorgement  may  be  reduced.  Suckling  by  the  breast  or 
bottle  usually  serves  to  check  the  bleeding  by  compressing  the  tissues. 
In  the  event  of  the  bleeding  continuing,  the  mouth  should  be  carefully 
examined,  and  a  piece  of  ice  in  a  napkm  may  be  given  to  the  child 
to  suck.  The  child  may  swallow  the  blood  and  later  regurgitate  it. 
Obstinate  bleeding  may  require  the  use  of  styptics,  but  these  should 
be  of  a  character  to  cause  only  coagulation  of  the  blood,  not  the 
destruction  of  tissue.  A  little  powdered  tannin  laid  upon  the  cuts 
acts  prompth",  as  does  also  a  small  amount  of  powdered  alum.  In 
some  cases  the  internal  treatment  may  be  necessary.  (See  Hemo- 
philia.) 

Death  has  occurred  from  hemorrhage  due  to  lancing,  in  cases  of 
presumably  hemorrhagic  diathesis;  so  that  inquiry  as  to  family 
history  would  be  a  wise  precaution.  Obtaining  such  a  history,  the 
gravity  of  the  symptoms  alone  warrant  the  operation.  In  the  absence 
of  such  a  history  the  operation  is  to  be  held  as  trivial.  If  it  occur,  it 
should  be  treated  as  indicated.     (See  Hemophilia.) 

The  operation  of  lancing  is  warranted,  even  when  the  gum  may 
be  likely  to  heal  over  the  tooth  by  formation  of  cicatricial  tissue, 
provided  symptoms  demand  it.  It  is  contra-indicated  in  diphtheria 
and  erysipelas,  owing  to  the  danger  of  infection. 

Shock  has  occurred  in  long-continued  debilitated  cases,  and  if 
feared,  a  triJQe  of  brandy  in  water  may  be  given  previous  to  the 
operation. 

It  is  within  the  knowledge  of  the  writer,  that  a  physician  has 
refused  to  lance  the  gums  in  a  case  diagnosed  as  cerebral  menin- 
gitis, even  when  death  was  prognosed  and  though  the  child  was  at 
an  age  rendering  pathological  dentition  possible,  and  in  spite  of  a 
history  of  pathological  dentition  in  a  previous  child  at  the  same  age. 
J.  Lewis  Smith^  concedes  the  similarity  of  occasional  symptoms  of 
pathological  dentition  and  cerebral  meningitis,  so  that  the  above 
therapy  was  foolish,  to  say  the  least,  and  especially  so  in  view  of  the 
probable  death,  which  did  occur.  As  a  contrary  specimen  of  judg- 
ment, a  mother  having  a  child  with  repeated  convulsions  "rubbed" 
the  gums  with  a  thimble  until  she  "felt"  the  teeth,  when  the  child 
sank  into  a  peaceful  sleep  and  had  no  more  convulsions.  In  many 
desperate  cases,  lancing  has  efi'ected  marvellously  rapid  recoveries, 
aided  by  judicious  handling  of  the  accessory  symptoms,  even  though 
all  hope  from  ordinary  therapy  had  been  abandoDed.  Physicians  in 
general  refuse  to  lance,  upon  the  ground  that  cicatricial  tissue  will 

1  Diseases  of  Children. 


78  DENTITION 

form  and  render  the  process  of  dentition  more  difficult.  This  is 
merely  substituting  a  supposititious  effect  for  a  needed  therapy. 
Observation  renders  it  a  question  as  to  the  knowledge  of  physicians 
of  the  location  of  the  teeth  and  the  pathological  process  of  dentition. 
Even  granting  cicatricial  tissue  to  possibly  retard  dentition,  there  is 
no  difficulty  in  again  lancing  if  conditions  require  it. 

Treatment  of  Stoma.titis. — Should  general  stomatitis,  with  or 
without  stomatitis  ulcerosa,  make  its  appearance,  the  mouth  is  to  be 
promptly  and  freely  sprayed  with  a  3  per  cent,  solution  of  hydrogen 
dioxid,  followed  by  a  spray  of  potassic  chlorate  (gr.  xx  to  5j),  which 
usually  affords  prompt  relief.  Should  the  spots  of  ulceration  not 
disappear  promptly,  the  mouth  and  tissues  about  the  ulcer  are  to 
be  guarded  by  soft  linen  napkins;  each  ulcer  is  dried  and  touched 
with  carbolic  acid,  full  strength.  The  spraying  is  to  be  repeated 
at  intervals  of  three  hours  during  the  waking  period. 

Treatment  of  Skin  Eruptions. — The  eruptions  which  appear 
upon  the  skin  during  dentition  may  be  a  source  of  annoyance  to 
the  child  by  causing  itching.  As  a  rule,  measures  directed  toward 
a  regulation  of  the  intestinal  functions  cause  a  disappearance  of  the 
skin  affections.  If  the  eruption  be  widespread  and  cause  much 
itching,  a  wash  of  phenol-sodique,  diluted  to  one-third  with  water, 
usually  affords  relief.  If  the  surfaces  be  then  dried  and  talcum 
powder  dusted  over  them  the  condition  is  much  alleviated.  About 
the  mouth  and  over  excoriated  surfaces  a  zinc  oxid  ointment  is  useful. 

Treatment  of  Intestinal  Symptoms. — The  fermentative  material 
in  the  bowel,  together  with  the  great  mass  of  bacteria  present,  should 
be  removed  by  the  use  of  a  cathartic.  It  is  indicated  in  both  con- 
stipation and  diarrhea.  Castor  oil  serves  well,  and  is  readily  taken 
by  children.  To  lessen  the  irritation  of  the  bowel,  laudanum  and 
powdered  acacia  may  be  added. 

The  following  formula  may  safely  be  used  even  at  six  months  of 
age: 

I^ — -Tincturse  opii gtt.  x 

Olei  ricini fgiss 

Pulveris  acacise 5ij 

Saccharini gr.  ij 

Aquae  cinnamomi q.  s.  ad    fgiij — M. 

Sig. — Shake  the  bottle,  and  give  one  teaspoonful  each  two  hours  if  needed. 

For  an  additional  six  months  of  age,  ten  drops  more  of  laudanum 
may  be  added  to  the  general  formula.  In  mild  cases,  olive  oil  in  half- 
teaspoonful  doses  may  be  substituted. 

Following  catharsis,  antacid  sedative  astringents  and  intestinal 
antiseptics  are  indicated: 


PATHOLOGICAL  FIRST  DEXTITION  79 

I^ — Saloli 3J 

Bismuthi  subnitratis 3ij 

Misturse  cretse ad  f§iij — M. 

Sig. — One  teaspoonful  every  four  hours.     (Biddle.) 

I^ — Tincturae  opii gtt.  xvj 

Bismuthi  subnitratis 3ii 

Misturae  cretae f5iss 

Syr.  simp fgiss — M. 

Sig. — Shake  well,  and  give  in  teaspoonful  doses  every  four  hours.      (Barrett.) 

The  virtues  of  both  formulse  may  be  obtained  by  including  the 
laudanum  (gtt.  xii)  with  the  salol  formula. 

Listerine  in  10-drop  doses,  in  water,  every  three  hours,  serves 
as  an  intestinal  antiseptic. 

The  gums  are,  of  course,  to  be  lanced  at  the  outset,  if  the  diarrhea 
be  due  to  pathological  dentition.  Following  the  intestinal  antisepsis, 
the  general  debihty  and  possible  intestinal  toxemia  are  to  have  care- 
ful attention,  and  the  child's  food  is  to  be  properly  adjusted  to 
its  needs.  If  the  child  is  being  nursed  by  a  capable  and  healthy 
mother,  this  is  to  be  regarded  as  the  best  form  of  food  supply,  but  if 
not  so  nursed,  proper  artificial  feeding  is  to  be  resorted  to. 

J.  Lewis  Smith  claims  that  upon  the  following  diet,  ill-conditioned 
children  under  his  care  in  the  hospital  escape  summer  diarrhea  and 
thrive;  the  diet  is  therefore  here  introduced. 

For  children  not  nourished  on  breast  milk  of  good  quality,  and 
those  over  three  months,  he  recommends  the  following  substitutes: 

1.  Heat  barley  flour  in  a  double  boiler,  the  water  in  the  outer  vessel 
to  be  kept  boiling  for  five  to  seven  days,  to  burst  the  starch  granules 
(Robinson's  prepared  barley  flour  can  be  bought) . 

2.  Take  of  this  flour  one  tablespoonful,  add  25  or  30  tablespoon- 
fuls  of  boiling  water,  and  boil  and  mix  for  five  minutes.  Cool  to 
blood  heat,  add  1  dram  of  diastase  to  change  the  starch  to  dextrin 
and  maltose.  Forbes'  diastase  or  Taka-diastase  can  be  bought.  Of 
the  latter,  1  gram  will  change  300  grains  of  starch  to  sugar,  therefore 
a  half-dram  only  need  be  used. 

Pasteurize  milk  by  heating  for  twenty  minutes  to  160°  F.  Cool 
quickly  on  ice  and  let  the  cream  separate.  To  two  and  one-half 
ounces  of  the  upper  half,  add  a  little  peptogenic  milk  powder  (Fair- 
child's),  to  peptonize  it.  He  mixes  this  peptonized  milk  with  three 
and  one-half  ounces  of  the  above  dextrinized  gruel  at  a  meal,  and  feeds 
the  infant  nine  or  ten  times,  at  two-hour  intervals.  Before  feeding, 
he  administers  a  few  drops  of  a  digestive  ferment. 

For  use  in  emergency,  he  recommends  two  heaped  teaspoonfuls 
of  condensed  milk  to  fifteen  teaspoonfuls  of  boiled  water,  as  equiva- 
lent to  seventeen  teaspoonfuls  of  ordinary  milk. 


80 


DENTITION 


He  gives  the  following  table  of  quantities  of  food  required  by 
infants;  either  breast  or  modified  cow's  milk  to  be  used. 


Number  of 

Total  daily 

At  each  feeding. 

daily  feedings. 

quantity. 

During  the  first  week 

1 

ounce 

10 

10  ounces 

At  the  third  week 

U 

ounces 

10 

15        " 

At  the  sixth  week 

2 

8 

16        " 

At  the  third  month 

3 

8 

24       " 

At  the  fourth  month 

4 

7 

28       " 

At  the  sixth  month  . 

6 

6 

36       " 

At  the  tenth  to  twelfth  month 

8 

5 

40       " 

White,  following  Starr,  gives  the  following  schedule  of  the  diet  of  a 
hand-fed  infant  from  birth  upward,^  which  will  serve  as  a  suggestive 
and  useful  guide: 

Diet  During  the  First  Week. 

Cream fSiiJ 

Sugar  of  milk gr.  sv 

Whey fgss,  foij 

Water fgss,  fSiJ 

This  portion  to  be  given  every  two  hours  from  5  a.m.  to  11  p.m.,  and  in  some  instances 
once' or  twice  during  the  night. 

Diet  from  the  Second  to  the  Fifth  Week. 

MUk fgss 

Cream fjij 

Sugar  of  milk gr.  xv 

Water fgj 

This  portion  to  be  given  every  two  hours  from  5  a.m.  to  11  p.m. 

Diet  from  the  Fifth  Week  to  the  End  of  the  Second  Month. 

Milk 'fSJ,  fSiJ 

Cream fgss 

Sugar  of  milk gr.  xxx 

.  Water       . fgj,  fSiJ 

This  portion  to  be  given  every  two  hours. 

Diet  During  the  Third  Month. 

Milk fgiiss 

Cream fgss 

Sugar  of  milk 5j 

Water fgj 

This  portion  to  be  given  every  two  and  one-half  hours. 

Diet  During  the  Fourth  and  Fifth  Months. 

Milk ■ fgiiiss 

Cream fgss 

Sugar  of  milk gj 

Water fgj 

This  portion  to  be  given  every  three  hours. 


I  Diseases  of  the  Digestive  Organs  in  Infancy  and  Childhood,  by  Louis  Starr,  M.D. 


PATHOLOGICAL  FIRST  DENTITION  81 

Diet  During  the  Sixth  Month. 

Milk fgivss 

Cream fgss 

Sugar  of  milk 5J 

Water fgj 

This  portion  to  be  given  four  times  daily. 

Two  other  meals — morning  and  mid-day — may  be  as  follows: 

Milk    . fgivss 

Cream f5ss 

Mellin's  Food 5j 

Hot  water fgj 

Dissolve  the  MeUin's  Food  in  the  hot  water,  and  add,  with  stirring,  to  the  previously 
mixed  milk  and  cream. 

In  the  seventh  month,  the  Mellin's  Food  may  be  increased  to  two 
teaspoonfuls  and  given  three  times  daily. 

Throughout  the  eighth  and  ninth  months,  five  meals  a  day  will  be 
sufficient — at  7  and  10.30  a.m.,  2,  6,  and  10  p.m. 

Milk f5vis3 

Cream fgss 

Sugar  of  milk 5J 

Water fgj 

This  portion  for  the  first  and  last  meals. 

For  the  other  three  meals,  1  tablespoonful  of  Mellin's  Food  may  be 
added,  or  1  teaspoonful  of  "flour-ball"  may  be  given  twice  daily, 
instead  of  the  Mellin's  Food — say  at  the  second  and  fourth  meals. 

Diet  for  the  Tenth  and  Eleventh  Months. 

First  meal,  7  a.m.  : 

Milk fSviiiss 

Cream fgss 

MeUin's  Food gss 

(Or  "flour-ball"  or  barley  jelly 5ij) 

Water fgj 

To  be  used  only  when  Mellin's  Food  is  employed. 

Second  meal,  10.30  a.m.  :  Eight  ounces  of  warm  milk. 

Third  meal,  2  p.m.:  The  yolk  of  an  egg  lightly  boiled  with  stale 
bread  crumbs. 

Fourth  meal,  6  p.m.  :  Same  as  first. 

Fifth  meal,  10  p.m.  :  Same  as  second. 

On  alternate  days  the  third  meal  may  consist  of  1  teacupful  (f§vj) 
of  beef  tea  containing  a  few  stale  bread  crumbs. 

Beef  tea,  for  an  infant,  is  made  in  the  following  way :  One-half  pound 
of  fresh  rump  steak,  free  from  fat,  is  cut  into  small  pieces,  and  put 
with  1  pint  of  cold  water  into  a  covered  tin  saucepan.    This  must 


82  DENTITION 

stand  by  the  side  of  the  fire  for  four  hours,  then  be  allowed  to  simmer 
gently  (never  boil)  for  two  hours,  and,  finally,  be  thoroughly  skimmed 
to  remove  all  grease. 

A  further  variation  can  be  made  by  occasionally  using  mutton, 
chicken,  or  veal  broths  instead  of  beef  tea. 

DIET   FROM  THE   TWELFTH  TO   THE   EIGHTEENTH  MONTH 
(five   MEALS   A   DAY) 

First  meal,  7  a.m.  :  A  slice  of  stale  bread  broken  and  soaked  in  a 
breakf astcupf ul  (f§  viij)  of  new  milk. 

Second  meal,  10  a.m.:  A  teacupful  of  milk  (f§vj)  with  a  soda 
biscuit  or  thin  slice  of  buttered  bread. 

Third  meal,  2  p.m.  :  A  teacupful  of  beef  tea  (f§  vj)  with  a  slice  of 
bread,  1  good  tablespoonful  of  rice,  and  milk  pudding. 

Fourth  meal,  6  p.m.  :  Same  as  first. 

Fifth  meal,  10  p.m.:  One  tablespoonful  of  Mellin's  Food  with 
1  breakfastcupful  of  milk. 

To  alternate  with  this : 

First  meal,  7  a.m.  :  The  yolk  of  one  egg  slightly  boiled,  with  bread 
crumbs;  1  teacupful  of  new  milk. 

Second  meal,  10  a.m.:  A  teacupful  of  milk  with  a  thin  slice  of 
buttered  bread. 

Third  meal,  2  p.m.:  A  mashed  boiled  potato,  moistened  with  4 
tablespoonfuls  of  beef  tea;  2  good  tablespoonfuls  of  junket. 

Fourth  meal,  6  p.m.:  A  breakfastcupful  of  new  milk  with  a  slice 
of  bread,  broken  up  and  soaked  in  it. 

Fifth  meal,  10  p.m.  :  Same  as  second. 

The  fifth  meal  is  often  unnecessary,  and  sleep  should  not  be  dis- 
turbed for  it.  At  the  same  time,  should  the  child  aw^ake  an  hour  or 
more  before  the  first  meal  time,  he  should  break  his  fast  upon  a  cup 
of  warm  milk,  and  not  be  allowed  to  go  hungry  until  the  set  breakfast 
hour. 


DIET   FROM   EIGHTEEN  MONTHS   TO   THE   END    OF   TWO   AND    ONE- 
HALF   YEARS    (four  meals   A   DAY) 

First  meal,  7  a.m.:  A  breakfastcupful  of  new  milk;  the  yolk  of 
one  egg  lightly  boiled;  two  thin  slices  of  bread  and  butter. 

Second  meal,  11  a.m.:  A  teacupful  of  milk  with  soda  biscuit. 

Third  meal,  2  p.m.:  A  breakfastcupful  of  beef  tea,  mutton  or 
chicken  broth,  a  thin  slice  of  stale  bread,  a  saucer  of  rice,  and  milk 
pudding, 


PATHOLOGICAL  FIRST  DENTITION  83 

Fourth  meal,  6.30  p.m.:  A  breakfastcupful  of  milk  with  bread 
and  butter. 

On  alternate  days: 

First  meal,  7  a.m.  :  Two  tablespoonfuls  of  thoroughly  cooked  oat- 
meal or  wheaten  grits,  with  sugar  and  cream;  1  teacupful  of  new 
milk. 

Second  meal,  11  a.m.  :  A  teacupful  of  milk  with  a  slice  of  bread  and 
butter. 

Third  meal,  2  p.m.:  One  tablespoonful  of  underdone  mutton, 
pounded  to  a  paste;  bread  and  butter,  or  a  mashed  potato  moistened 
with  good  plain  dish  gravy;  a  saucer  of  junket. 

Fourth  meal,  6.30  p.m.:  A  breakfastcupful  of  milk,  a  slice  of  soft 
milk  toast,  or  a  slice  or  two  of  bread  and  butter. 

The  foregoing  schedule  must,  of  course,  be  regarded  as  an  average. 
Many  children  can  bear  nothing  but  milk  food  up  to  the  age  of  two 
or  even  three  years,  and  provided  enough  be  taken,  no  fear  for  their 
nutrition  need  be  entertained.  The  rule  to  adopt  is,  if  a  child  be 
thriving  on  milk,  it  is  never  to  be  forced  to  take  additional  food, 
merely  because  a  certain  age  has  been  reached.  Let  the  healthy 
appetite  be  the  guide. 

The  following  is  recommended  by  Starr  as  a  modified  milk  diet, 
and  as  a  substitute  for  mother's  milk  while  weaning: 

Pasteurized  cream .    fgss 

Pasteurized  milk fgiiss 

Sugar  of  milk 3ss 

Water,  boiled fgj 

Should  this  not  satisfy  the  infant,  increase  the  ingredients  (except  cream)  to  6,  8, 
or  12  ounces. 

Hare^  recommends  the  following  diet  list,  followed  in  his  hospital 
practice : 

DIET   FOR  A   CHILD   AGED  TWO   YEARS. 

Breakfast,  7.30  a.m.:  Milk.  The  lightly  boiled  yolk  of  an  egg; 
thin  bread  and  butter  (the  bread  to  be  one  da}^  old). 

Lunch,  1 1  A.M. :  Milk.    A  thin  slice  of  bread  and  butter. 

Dinner,  1.30  p.m.:  Beef  tea,  or  small  piece  of  minced  roast  beef 
or  mutton,  devoid  of  gristle.  One  well-mashed  potato,  moistened  with 
gravy.    Rice^and  milk. 

Supper,  6  p.m.  :  Milk.    Bread  and  butter. 

For  drink:  Boiled  or  filtered  water, 

'  Practical  Therapeutics. 


84  DENTITION 

DIET   FOR  A    CHILD   AGED    ONE    YEAR    (fIVE   MEALS   A   DAY). 

First  meal,  7  a.m.:  2  teaspoonfuls  of  grated  flour-ball  (prepared 
as  directed  below)  in  |  pint  of  milk. 

Second  meal,  10.30  a.m.:  |  pint  of  milk  with  4  tablespoonfuls 
of  lime  water. 

Third  meal,  2  p.m.  :  The  yolk  of  one  egg,  beaten  up  in  1  teacupful 
of  milk. 

Fourth  meal,  5.30  p.m.  :  Same  as  the  first. 

Fifth  meal,  11  p.m.:  Same  as  the  second. 

Flour-ball  is  to  be  made  by  taking  one  pound  of  good  flour — 
unbolted,  if  possible — tie  it  up  very  tightly  in  a  pudding-bag;  put  it 
in  a  pot  of  boiling  water  early  in  the  morning,  and  let  it  boil  until 
bedtime,  then  take  it  out  and  let  it  dry.  In  the  morning,  peel  off  the 
surface  and  throw  away  the  thin  rind  of  dough,  and  with  a  grater, 
grate  down  the  hard,  dry  mass  into  a  pow^der.  To  use  this,  take 
from  1  to  2  teaspoonfuls  of  the  powder,  rub  it  down  until  smooth 
with  a  tablespoonful  of  cold  milk,  and  add  1  tumblerful  of  hot  milk, 
stirring  it  well  all  the  time. 

DIET   FOR   A   CHILD   AGED   FROM   SIX  TO   TWELVE   MONTHS    (fIVE 
MEALS   A   day). 

First  meal,  7  a.m.:  Mellin's  Food,  1  tablespoonful;  or  flour-ball 
grated,  1  or  2  teaspoonfuls  (prepared  as  directed  above) ;  hot  water, 
4  tablespoonfuls;  warm  milk,  enough  to  make  ^  pint.  Dissolve  the 
Mellin's  Food,  or  rub  down  the  grated  flour-ball  in  the  hot  water  by 
stirring,  then  add  the  milk;  mix  thoroughly. 

Second  meal,  10.30  a.m.,  and  third  meal,  2  p.m.:  A  breakfast- 
cupful  of  milk,  with  4  tablespoonfuls  of  lime  water. 

Fourth  meal,  5.30  p.m.  :  Same  as  first. 

Fifth  meal,  10.30  p.m.  :  Same  as  second. 

Treatment  of  Nervous  Conditions. — If  nervous  reflexes,  great 
irritability,  or  cerebral  congestion  appear,  attention  should  be 
directed  to  the  condition  of  the  bowels  and  the  teeth. 

If  constipation  or  diarrhea  exist,  a  cathartic  is  given  and  the  gums 
are  lanced.    A  cerebral  sedative  is  to  be  prescribed. 

I^ — Chloralis  hydratis gr.  ij 

Sodii  bromidi gr.  v 

Aquae  menthse  piperitse fgij — M. 

Sig. — Per  orem.     One  dose;   enlarge  formula  for  repetition  as  needed. 

If  convulsions  be  threatened,  the  clothing  should  be  loosened  and 
cool  applications  made  to  the  head. 


CONSTITUTIONAL  STATES  MODIFYING  DENTITION        85 

If  the  child  be  in  convulsions,  it  should  be  immersed  to  the  waist 
in  water  as  hot  as  can  be  borne,  to  which  has  been  added  2  table- 
spoonfuls  of  common  mustard  flour,  and  cool  water  poured  over  its 
head,  when,  as  a  rule,  the  symptoms  promptly  subside.  Chloroform, 
which  children  endure  well,  may  be  administered. 

After  immersion,  a  rectal  injection  of  1  dram  of  glycerin  or  a 
glycerin  suppository  will  usually  cause  a  free  stool.  A  cerebral 
sedative  should  be  administered. 

I^ — Chloralis  hydratis gr.  ij 

Sodii  bromidi gr.  v 

Starch  paste Sij — M. 

Sig. — To  be  administered  per  rectum.     (Atkinson.) 

It  is  well  also  to  administer  a  cathartic,  to  unload  the  intestines  of 
irritating  substances  possibly  present. 

After  sleep,  if  appearances  indicating  dental  irritation  be  observed, 
gum  lancing  is  practised.  It  is  wise  that  this  operation  be  thus 
deferred,  as  convulsions  may  be  precipitated  by  the  act  of  lancing 
when  the  nervous  system  of  the  child  is  overexcited.  The  removal  of 
intestinal  irritants,  by  a  cathartic  given  per  orem  is  also  in  order, 
before  lancing. 

It  has  been  repeatedly  noted  that  when  evidence  of  marked 
cerebrospinal  irritation  is  present,  for  which  no  probable  source  can 
be  assigned,  and  an  examination  of  the  gums  shows  no  apparent  local 
disturbance,  yet  if  it  be  at  a  period  when  one  or  more  teeth  are  in 
process  of  eruption,  but  are  still  covered  or  bound  down  by  gum 
tissue,  if  gum  lancing  be  practised,  relief  is  immediate  and  the  lancing 
may  even  avert  a  threatened  attack  of  eclampsia.  It  is  presumed  that 
these  are  cases  of  pulp  irritation,  in  which  a  failure  of  resorption  of 
tissue  in  advance  of  the  tooth  crown  has  caused  pressure  upon  the 
pulp  forming  the  root  end. 

CONSTITUTIONAL   STATES   MODIFYING   DENTITION. 

Children  who  are  the  victims  of  hereditary  syphilis,  usually  cut 
their  teeth  very  early;  the  alveolar  process  being  in  many  cases 
insufficient.  Cases  are  recorded  where  children  have  been  born  with 
crowns  of  teeth  visible  upon  the  gum,  there  being  no  evidence  of  root 
formation,  the  crowns  being  loosely  held  to  the  gum  by  fibrous 
tissue.  It  is  necessary  to  remove  these  loose  crowns,  to  permit  the 
infant  to  suckle.  The  presence  of  loose  crowns  of  teeth  is  a  condition 
pointing  to,  though  by  no  means  diagnostic  of,  hereditary  syphilis. 
Particularly  in  children  in  whom  a  history  of  hereditary  syphilis  is 
obtainable,  the  process  of  dentition  may  be  accompanied  by  rapid 


86  DENTITION 

and  frequently  widespread  breaking  down  of  the  soft  tissues,  over 
and  about  erupting  teeth.  Local  measures  of  treatment  seem  to  be 
of  but  little  avail,  except  that  antiseptic  treatment  undoubtedly 
prevents  complications  from  extraneous  infection.  In  rachitis  the 
teeth  are  generally  delayed  in  eruption.  A  delay  beyond  the  age  of 
nine  months  while  not  evidence  of  rickets  in  itself  should  prompt 
suspicion  of  the  disease  and  its  prodroma  should  be  looked  for  as 
described  by  J.  Lewis  Smith,  M.D.  It  is  a  disease  largely  due  to 
improper  diet  and  bone  starvation  causing  increased  cell  growth  and 
imperfect  deposition  of  lime  salts  so  that  the  bones  contain  about 
20  per  cent,  of  inorganic  as  against  the  normal  of  67  per  cent. 

There  are  said  to  be  many  cases  of  slight  rachitis  even  among  the 
well  to  do,  though  largely  found  among  the  poor  and  ill -nourished. 
The  shape  of  the  cranium  is  often  altered,  due  to  the  brain  and  pillow 
pressure  upon  the  soft  bones.  These  craniotabes  occur  under  one 
year,  often  under  eight  months  of  age.  The  other  prodromal  symp- 
toms are  "indigestion,  or  intestinal  catarrh  with  flatulence,  unhealthy 
stools  and  poor  and  capricious  appetite." 

Fretfulness,  disturbed  sleep,  free  perspiration  from  the  head  and 
neck  with  dry  trunk  and  extremities,  tenderness  over  a  considerable 
part  of  the  body  due  to  the  rachitic  effect  upon  bones  and  muscles 
are  other  symptoms.  Later  skeletal  changes  occur  resulting  in 
deformities.  Spasm  of  the  glottis  is  due  to  the  craniotabes.  The 
treatment  of  the  condition  is  purely  medical. 

In  children  classified  indefinitely  as  strumous,  which  may  mean  the 
children  of  syphilitic  or  tuberculous  parents,  or  those  with  no  such 
history  whose  surroundings  are  of  the  most  unhygienic  kind,  the 
process  of  dentition  may  not  only  have  an  untoward  course,  but 
phagedenic  ulcerations  may  occur.  It  is  usually  in  the  degree  of  a 
child's  debility,  either  inherited  or  acquired  through  improper  care, 
that  dentition  assumes  morbid  features.  The  treatment  of  such  cases 
must  be  directed  to  raising  the  health  standard.  As  local  therapeusis, 
no  measures  seem  more  effective  than  the  sprays  of  hydrogen  dioxid 
first;  next,  potassium  chlorate,  and,  if  conditions  indicate  it,  sprays  of 
dilute  listerine,  which  is  stimulant,  antiseptic,  and  slightly  astringent. 

Infantile  Scurvy. — Cases  are  reported  in  which  the  improper 
feeding  of  children  has  been  followed  by  evidences  of  scorbutus.  It 
occurs  usually  in  bottle-fed  babies  confined  to  patent  foods,  the 
nutritive  element  being  lacking.  The  gums  become  tumid,  and 
hemorrhagic  extravasations  occur  in  their  substance;  the  periosteum 
is  stripped  from  the  margins  of  the  alveolar  walls,  the  soft  tissues 
hanging  in  discolored,  pendulous  masses  about  and  beyond  the  teeth 
if  any  be  erupted. 


THE  SECOND  DENTITION  87 

The  child  is  peevish,  listless,  and  feeble.  There  is  apparent  pain 
in  the  limbs. ^    The  urine  may  be  bloody  even,  as  a  first  sign. 

The  treatment  is  largely  systemic,  and  consists  of  using  fresh  cow's 
milk  modified  to  conform  to  human  milk,  and  in  the  administration 
of  fresh  lemon  juice,  preferably  boiled,  allowed  to  settle,  and  the 
supernatant  fluid  used,^  or  orange  juice  is  also  used. 

The  mouth  should  be  sprayed  with  sedative  antiseptics,  such  as 
potassium  chlorate  in  hydrogen  dioxid. 

THE   SECOND   DENTITION. 

The  permanent  teeth  are  nearly  all  formed  from  cords  given  off 
at  the  sixteenth  week  from  the  sides  of  the  cord  of  the  corresponding 
temporary  teeth  as  far  back  as  the  bicuspids,  which  are  given  off 
from  the  cords  of  the  first  and  second  temporary  molars;  the  sacs 
are  formed  and  lie  lingual  to  and  above  the  sacs  of  the  temporary 
teeth  (Figs.  41  and  42).  At  the  fifteenth  week  of  fetal  life  the 
cords  of  the  first  permanent  molars  are  given  oft'  from  the  mucous 
membrane,  at  the  third  month  after  birth  the  cord  for  the  second 
molar  is  given  off  from  that  of  the  first  molar,  and  at  three  years 
after  birth  the  cord  of  the  third  molar  arises  from  that  of  the  second 
molar.  At  birth  therefore  44  teeth  are  in  process  of  development  and 
without  doubt  an  impress  is  made  upon  the  enamel  organs  by  the  con- 
dition of  the  mother.  The  same  is  no  doubt  true  of  all  delicate  tissues. 
As  a  prophylactic  of  the  health  or  vital  resistance  of  the  child  as  well 
as  for  its  good  development  of  enamel  the  mother  should  have  all 
possible  dietary  and  hygienic  consideration.  After  eruption  and  root 
completion  in  the  temporary  teeth  and  some  development  of  the  crowns 
of  the  permanent  teeth  the  relation  of  the  cr}T)ts  of  the  permanent 
teeth  to  the  temporary  teeth  is  as  shown  in  Fig.  40. 

By  reference  to  Fig.  40,  it  will  be  seen  that  at  six  and  one-half  years 
of  age,  the  twenty  temporary  teeth  are  still  all  in  position,  and  that 
taking  their  places  in  the  line  of  the  arch,  are  the  four  permanent  first 
molars,  the  roots  of  which  are  still  incomplete. 

These  molars  do  not  replace  any  temporary  teeth,  but  erupt  back 
of  the  second  temporary  molars  and  during  the  "change"  support 
the  jaws  with  the  assistance  of  the  temporary  molars  until  the  per- 
manent incisors  are  fully  erupted,  and  with  the  aid  of  the  incisors, 
until  the  bicuspids  come  into  occlusion.  Their  office  as  jaw  props 
and  organs  of  mastication  during  the  change  is,  therefore,  very 
important.    Of  their  later  function,  more  will  be  said  farther  on. 

1  Hare,  Practical  Therapeutics.  ^  Ibid. 


88 


DENTITION 


At  six  and  one-half  years,  the  crowns  of  the  permanent  incisors 
lie  in  the  relations  shown,  with  the  temporary  central  roots  resorbed 
and  the  lateral  root  partly  so.  Their  crowns  are  practically  complete, 
but  the  roots  are  unformed. 

The  cuspid  crown  in  its  crypt,  lies  well  above  and  lingual  to  the 
unresorbed  temporary  cuspid  root.  The  roots  of  the  first  and  second 
temporary  molars,  a  trifle  resorbed  upon  the  inner  side,  embrace  the 
formed  crowns  of  the  first  and  second  bicuspids. 

Fig.  41 


Tooth  follicles  for  deciduous  and  permanent  teeth,  three  months  after  birth:  1,  2, 
tooth  sacs  of  deciduous  teeth;  3,  periosteum  of  hard  palate;  4,  tooth  sacs  of  permanent 
teeth.     (Broomell.) 

Fig.  42 


Deciduous  molars  with  tooth  sacs  for  permanent  bicuspids  attached  to  the  gingival 

tissue.     (Broomell.) 


In  their  crypts  back  of  the  first  molars,  lie  the  forming  crowns  of 
the  second  permanent  molars.  The  third  molars  are  not  in  evidence 
in  the  illustration,  but  their  development  is  in  progress. 

It  will  be  seen  that  the  permanent  central  and  lateral  incisors 
replace  the  temporary  central  and  lateral  incisors,  the  permanent 
cuspid  the  temporary  cuspid,  and  the  first  and  second  bicuspids  the 
first  and  second  temporary  molars,  respectively. 


THE  SECOND  DENTITION  89 

From  this  age  to  adult  age,  as  previously,  the  jaw  undergoes  constant 
change,  enlarges  by  constant  resorptions  and  depositions  of  bone,  and 
changes  its  contour  to  conform  to  the  changes  occurring  throughout 
the  body,  and  to  accommodate  the  permanent  teeth,  which  are  in 
general  terms  larger  and  more  numerous  than  the  temporary  teeth. 

It  is  regarded  as  normal  that  at  about  four  to  five  years  of  age 
spaces  shall  appear  between  the  anterior  temporary  teeth  due  to  the 
gradual  enlargement  of  the  arches  due  to  developmental  forces 
probably  exerted  in  part  by  the  descent  of  the  permanent  teeth, 
though  development  to  a  type  or  a  vital  element  is  also  in  action. 

It  may  be  said  that  the  alveolar  process  built  about  the  roots  of 
temporary  teeth  and  the  roots  of  the  temporary  teeth  are  all  resorbed 
during  the  replacement  of  the  latter,  and  that  when  the  crowns  of 
the  permanent  teeth  are  fully  erupted,  new  alveolar  process  is  built 
up  about  their  roots.  Any  subsequent  change  in  the  position  of  the 
permanent  teeth  is  accompanied  by  an  alteration  in  the  alveolar  pro- 
cess, and  after  extraction  the  latter  is  resorbed,  but  upon  an  implan- 
tation (which  see)  being  done,  new  process  will  form.  Its  dependence 
upon  the  teeth  is,  therefore,  evident. 

The  following  table  gives  the  approximate  ages  for  the  eruption 
of  the  permanent  teeth : 

First  molars Sf  to    7  years 

Central  incisors 7    to    8  years 

Lateral  incisors 8    to    9  years 

First  bicuspids 10    to  11  years 

Second  bicuspids 11    to  12  years 

Cuspids,  the  lower  usually  preceding  by  a  year  or  more  12    to  14  years 

Second  molars 12    to  15  years 

Third  molars ■ 16    to  20  years 

and  indefinitely  beyond 

The  Process  of  Resorption  of  the  Temporary  Roots. — After  com- 
pletion of  formation,  the  roots  of  the  temporary  teeth  remain  in  this 
state  but  a  short  time,  as  their  successors  are  ready  to  advance  to 
their  places. 

Comparing  the  ages  at  which  resorption  begins  with  the  ages  at 
which  it  is  complete  (eruption  of  permanent  teeth)  (see  Fig.  43),  it 
will  be  noted  that  approximately  three  and  one-half  years  are  required 
in  all  cases  for  the  removal  of  the  temporary  roots.  Therefore,  to 
determine  the  age  at  which  absorption  begins,  deduct  three  and  one- 
half  years  from  the  date  of  eruption  of  the  corresponding  permanent 
tooth.  The  degree  of  resorption  at  any  age  is  shown  in  the  table. 
The  exact  degree  may  be  determined  by  radiography  (Fig.  47). 

At  the  time  the  permanent  tooth  begins  its  advance,  it  lies  in  a 
bony  crypt  above  and  lingual  to  its  predecessor,  except  in  the  case 


00 


DENTITION 


of  the  bicuspids,  which   lie   between  the  roots  of   the  temporary 
molars  (Figs.  40,  41,  and  42). 

Fig.  43 


li       A 

«\        it-LA. 


jA ^ 


Decalcification  of  the  deciduous  teeth.     The  numbers  indicate  years.     (Peirce.) 


Fig.  44 


Fig.  45 


Showing  the  relations  of  an  erupt- 
ing permanent  tooth  to  its  deciduous 
predecessor.  A,  A,  A,  odontoclasts 
in  absorbent  organ. 


r 


The  structure  of  the  absorbent  organ, 
showing  multinucleated  or  giant  cells 
(odontoclasts).     (Tomes.) 

Fig.  46 


i    kJ^ 


Imprisonment  of  second  temporary 
molar;  resorption  of  its  roots,  with 
absence  of  second  bicuspid.  (Skiagraph 
by  Custer.) 


Each  crypt  has  its  own  follicle  wall  enclosing  a  permanent  tooth 

crown. 


THE  SECOND  DENTITION  Ol 

In  the  follicular  wall  overlying  the  crown,  appear  large  multinu- 
cleated cells,  the  origin  of  which  is  unknown,  but  which  by  some  are 
thought  to  be  transformed  osteoblasts,  by  others  leukocytes  (Figs. 
44  and  45).  The  latter  is  the  probable  explanation,  as  analogous 
cells  are  found  about  tissues  or  foreign  bodies  about  to  undergo 
resorption  anywhere  in  the  body.  (See  Resorption.)  In  the  par- 
ticular situation  under  consideration  they  are  called  odontoclasts. 
The  tissue  between  the  root  and  crown  has  by  Tomes  been  given 
the  name  of  the  "absorbent  organ"  (Figs.  44  A,  and  45).  These 
giant  cells  have  a  solvent  or  digestive  function  not  understood,  but 
which  is  competent  to  remove  both  the  organic  and  inorganic  matter 
of  cementum  and  dentin,  and  evidences  of  action  upon  enamel  in 
other  situations  are  not  wanting.  (See  Resorption  of  Enamel.) 
That  the  solvent  is  acid,  is  shown  by  the  evidence  of  decalcification 
about  the  area  of  resorbed  enamel  of  unerupted  crowns  of  some 
permanent  teeth.  It  is  a  curious  fact  that  no  evidence  of  decalci- 
fication of  the  permanent  crown  has  been  demonstrated  to  result 
from  the  proximity  of  the  multinucleated  cells  in  cases  of  physio- 
logical resorption  of  roots.  One  at  first  thought  might  connect  opaque 
spots  with  this  process,  but  the  fact  of  a  good  enamel  glaze,  as  a  rule, 
together  with  the  depth  of  the  spot  makes  it  a  totally  difficult  picture 
from  the  grotto-like  resorption  or  the  roughened  decalcification.  In 
all  probability  the  enamel  is  protected  by  the  presence  of  Xasmyth's 
membrane,  which  is  resistant  to  acids.  These  cells  are  probably 
invited  by  irritation  due  to  pressiu-e  of  the  advancing  permanent 
tooth  crown,  as  the  resorption  is  almost  always  found  at  the  point  of 
approximation  of  the  crown  with  the  root,  or,  in  other  words,  at  the 
pressm-e  point  (Fig.  47). 

Cases  of  resorption  of  temporary  roots  without  the  presence  of  a 
permanent  crown  are,  however,  noted  and  explained  by  Tomes 
upon  the  ground  that  resorption  is  a  vital  act  independent  of  the 
pressure  exerted  (Fig.  46).  As  resorption  of  permanent  roots, 
however,  has  often  occurred  from  pressure  of  the  crown  of  another 
tooth  and  occurs  at  the  pressure  point  in  physiological  resorption, 
localized  irritation,  even  in  the  absence  of  a  permanent  crown,  must 
be  credited  with  a  large  influence  in  the  process.  It  is  to  be  remem- 
bered also  that  in  the  absence  of  the  pressure,  resorption  often  does 
not  occur,  at  least  for  twenty-five  or  more  years — e.  g.,  when  laterals 
are  absent  and  the  permanent  cuspids  erupt  to  the  side  of  the 
deciduous  cuspids  (Fig.  52). 

According  to  Tomes,  redeposition  of  cementum  occurs  in  pre- 
viously resorbed  areas  upon  temporary  roots;  a  fact  corresponding 


92 


DENTITION 


with  effects  noted  in  permanent  roots.     (See  Resorption  of  Perma- 
nent Roots.) 

Teeth  frequently  erupt  lingually  or  labially  to  their  corresponding 
temporary  teeth,  both  remaining  in  the  mouth.  It  is  almost  invari- 
ably the  rule,  upon  extraction  to  find  that  an  oblique  resorption  has 
occurred,  as  is  shown  in  the  right  upper  skiagraph  in  Fig.  47,  and 
generally  a  decided  hyperemia  is  seen  in  the  pulp  extending  upward 
for  perhaps  a  quarter  of  an  inch. 


Fig.  47 


Fig.  48 


Phases  of  resorption  of  temporary  roots. 
(Skiagraph  by  Price. i) 


Diagram  illustrating  the 
relation  of  a  resorbed  tem- 
porary root  and  the  perma- 
nent tooth,  also  the  involve- 
ment of  the  pulp  as  a  part 
of  the  resorbent  organ. 
Resorption  of  the  interior 
of  crown  of  a  temporary 
tooth.     From  actual  case. 


Doskow^  has  shown  by  the  prompt  loss,  by  absorption,  of  a  fairly 
firm  deciduous  cuspid,  crowned  to  bring  it  up  to  level  and  so  to 
usefulness,  that  such  an  operation  is  inadvisable  because  of  an  inher- 
ent tendency  of  an  absorbent  organ  to  become  established.  Again, 
a  permanent  tooth  undergoing  resorption  often  remains  firm,  until 
suddenly  the  strain  becomes  too  great. 

As  the  root  of  the  temporary  tooth  disappears,  the  pulp  continu- 
ously fuses  with  the  absorbent  organ,  so  that  when  the  crown  alone 
remains,  the  pulp  is  still  vital  (Figs.  44  and  48).  At  times,  it  seems 
to  take  up  the  resorbent  function  and  resorbs  the  crown  dentin  in 
some  cases  almost  entirely.  In  one  specimen,  a  circumscribed  portion 
of  the  cementum  and  of  enamel  were  removed  by  it,  at  the  point  of 
junction.     This  constituted  practically  a  case  of  perforation  by 


1  Items  of  Interest,  1901. 


3  Dental  Cosmos,  1907. 


THE  SECOND  DENTITION 


93 


resorption  (Fig.  48).  The  tooth  was  at  first  thought  to  be  suffused 
with  hemoglobin,  as  it  was  of  a  pink  color.  After  extraction  the 
absorbent  organ  was  found  as  a  papilla  attached  to  the  gum.  At 
times,  bay-like  excavations  in  the  crown  dentin  occur  (Fig.  159,  D). 
Dr.  A.  B.  Harrower  presented  the  "^Titer  with  a  radiograph  of  a 
case  in  which  a  second  temporary  molar  retained  at  thirteen  years 
excited  doubt  as  to  presence  of  a  bicuspid  successor.  The  bicuspid 
crown  lay  within  the  crown  of  the  temporary  molar,  the  dentin  of 
the  latter  entirely  resorbed  (Fig.  49).  When  the  root  resorption 
reaches  the  point  showTi  in  the  central  incisor  in  Fig.  40  the  tempo- 
rary tooth  is  loosened,  moves  about,  and  annoys  the  child,  who  may 
pick  it  out,  or  it  is  removed  by  extraction. 


Ftg.  49 


Bicuspid  within  the  crown  of  a  temporary  molar.     Note  formative  organs  below  root 
end.     Practice  of  Dr.  A.  B.  Harrower. 


Formation  of  the  Roots  of  Permanent  Teeth. — The  extent  of  root 
development  at  any  age  is  of  great  importance  in  view  of  canal  thera- 
peutics. Incomplete  roots  present  a  mechanical  difficulty  of  sealing 
the  apex  of  the  canal.  The  size  of  the  pulp  at  the  apical  foramen 
of  such  teeth  contraindicates  the  use  of  arsenic,  and  even  pressure 
anesthesia  is  often  unsuccessfully  applied. 

The  roots  are  developed  in  precisely  the  same  manner  as  in  the 
case  of  the  temporary  teeth,  by  the  combined  deposition  of  cementum 
by  the  osteogenetic  cells  of  the  follicle  wall,  which  is  drawn  up  on 
the  root  as  a  pericementum,  and  dentin  by  the  odontoblasts  of  the 
papilla,  which  is  drawn  up  as  a  pulp  (Figs.  39  and  49). 

The  extent  of  development  of  any  of  the  permanent  teeth  may  be 
seen  at  a  glance  by  reference  to  the  valuable  table  of  Peirce  (Fig.  50) . 
So  graphically  does  this  table  give  the  desired  information  that 
explanation  becomes  unnecessarj'.  It  may  here  be  noted  that  the 
end  of  a  completed  root  is  composed  of  cementum  and  that  the  apical' 
foramen  is  not  always  single  but  may  often  be  multiple  or  delta-like. 
(See  Index.) 


94 


DENTITION 


>1  >> 


o  ci  y^ 


000      CD-*        (M      OClCOloS 


Irregularities  of  Second  Dentition. — Some  temporary  teeth  may 
be  retained  long  after  adult  age  is  reached.  The  teeth  most  subject 
to  this  are  the  cuspids  and  second  temporary  molars. 

In  the  case  of  the  cuspids, 
the  permanent  cuspid  is  de- 
layed or  takes    an    unusual 
direction,  erupting  lingually 
or  labially,  or  at  times  being 
directed  into  the  place  nor- 
mally occupied  by  the  lateral 
incisors,  which  are  wanting, 
or    very  rarely,  the    cuspid 
erupts  posteriorly  to  the  first 
bicuspid.      At    about    forty 
years  of  age,  the  temporary 
cuspids  may  be  lost  by  re- 
sorption of  their  roots,  but 
until    such   time   should   be 
retained  if  usefully  filling  a 
space.      If     in    interference 
with    proper    alignment    or 
eruption  of   the   permanent 
cuspid,   they  should  be  ex- 
tracted.   Their   late   resorp- 
tion is  somewhat  pathological 
in   character,   and    probably 
due  to  or  incited  by  a  partial 
resorption  of   the    root  end 
during   the    descent  of    the 
permanent  cuspid  (Figs.  51, 
52,  and  53). 

The  late  enforced  loss  of 
the  temporary  cuspid  indi- 
cates the  advisability  of  an 
implantation  operation, 
though  a  small  bridge  held 
by  a  Carmichael  attachment 
to  the  first  bicuspid  and  a 
lug  against  the  lateral  or  cen- 
tral is  very  useful. 

The  molars  are  retained, 
as  a  rule,  because  of  an  ab- 
sence of  permanent  crowns 


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THE  SECOND  DENTITION 


95 


to  cause  resorption,  although  this  may  occur  without  such  pressure 
(Fig.  46).    I  have  seen  a  case  of  an  adult  lady  with  eight  deciduous 


Fig.  51 


Absence  of  upper  left  lateral  incisor,  with  permanent  cuspid  in  its  place;    two 
temporary  cuspids  retained.     Man,  aged  twenty-five  years. 

Fig.  52 


Absence  of  upper  lateral  incisors  and  right  bicuspid.     Retention  of  temporary  cuspids. 

From  an  adult. 

molars  in  place.  The  question  of  the  abnormal  development  or 
absence  of  permanent  germs,  or  of  the  state  of  the  roots  of  the 
temporary  tooth  may  be  settled  by  radiography *(Figs.  47  and  54). 


96 


DENTITION 


The  question  of  extraction  or  retention  depends  upon  the  diag- 
nosis. A  firm  temporary  tooth  should  never  be  extracted  simply  to 
allow  a  permanent  tooth  to  erupt  unless  the  presence  of  a  permanent 


Fig.  53 


Permanent  cuspid  erupted  posterior  to  the  first  bicuspid. 


Fig.  54 


tooth  in  the  jaw,  as  determined  by  radiograph  or  other  means,  gives 
reasonable  inference  that  the  permanent  tooth  is  held  back  by  the 
temporary  tooth.  In  most  cases  a  reasonable  delay  is  advisable. 
A  patient  of  the  writer's  wore  a  plate  for  thirteen  years  because  of  the 

injudicious  extraction  of  an  upper 
temporary  cuspid,  the  permanent 
tooth  appearing  at  twenty-six  years 
of  age. 

When  the  retention  of  temporary 
molars  and  cuspids  occurs,  they  are 
apt  to  occupy  an  occlusal  level,  lower 
than  that  of  the  permanent  teeth 
(Fig.  46).  They  may  not  be  in 
occlusion  at  all,  as  was  the  case  with 
the  eight  molars  just  referred  to. 
This  proves  the  fact  that  the  general 
occlusal  level  of  the  permanent  teeth 
is  farther  from  the  margin  of  the  alveolar  process  than  in  the  case  of 
the  temporary  teeth.  The  length  of  the  permanent  crowns  accounts 
for  this.  In  normal  replacement,  however,  the  occlusal  level  is  nearly 
the  same  for  the  temporary  molars  and  first  permanent  molar,  at 
least  until  the  change  is  made  by  the  eruption  of  the  bicuspid. 

The  devitilization  of  the  pulp  of  the  temporary  tooth  may  delay 
resorption  and  indicate  extraction.  The  imprisonment  of  a  temporary 
molar  has  been  accompanied  by  neurotic  or  mental  symptoms 
supposedly  ciu-ed  by  the  extraction  which  is  rational.  It  is  to  be 
remembered  that  in  case  of  premature  extraction  of  temporary 
teeth  the  date  of  eruption  of  the  permanent  successors  is  usually 


Retained  temporary  molar  with  bi- 
cuspid present.  (Radiograph  by  E 
Ballard  Lodge.) 


THE  SECOND  DENTITION 


97 


earlier  by  a  year  or  two,  of  which  fact  advantage  may  be  taken 
especially  in  cases  of  devitalized  temporary  molars. 


Fig.  55 


Fig.  56 


Retained   lower   temporary   molars,  Delayed    cuspid.       (Radiograph    by  E. 

bicuspid   absent.     (Radiograph  by  E.  Ballard  Lodge.) 

Ballard  Lodge.) 

Fig.  57 


Typical  occlusion.      (Cryer.) 


The  correct  placement  of  these  first  permanent  molars  seems  to 
determine  the  correctness  of  molar  occlusion,  at  least  in  the  mesio- 
distal  relation,  though  they  may  not  occupy  their  correct  bucco- 
lingual   positions.      Any    slight    forces    disturbing   the    mesiodistal 

7 


98  DENTITION 

relation,  causing  the  upper  first  molar  to  drift  anterior  to  its  correct 
occlusion  with  the  lower  molar,  will  result  in  an  abnormal  relation 
of  the  teeth  to  those  anterior  to  them  and  to  their  antagonists;  either 
upper  protrusion  or  upper  irregularities  will  occur. 

If  the  reverse  occur,  and  the  lower  molar  be  placed  anteriorly,  and 
the  upper  be  placed  normally  or  posterior  to  its  normal  position, 
prognathism  of  the  lower  teeth  ordinarily  results.  If  placed  too  far 
posteriorly,  retrusion  of  the  lower  teeth  will  occur. 

Fig.  58 


Malocclusion.     Class  I.     (Angle.) 

According  to  Angle,  the  misplacement  of  the  permanent  teeth 
erupting  early  causes  their  inclined  planes  to  direct  other  teeth  from 
normal  occlusion,  or  by  permitting  contraction  of  the  space  normally 
occupied,  particularly  in  the  lower  jaw,  permits  the  other  teeth  to 
assume  a  position  in  a  contracted  arch,  thus  again  causing  their 
inclined  planes  to  cause  contraction  in  the  opposite  arch,  with  a 
consequent  displacement,  buccolingually,  of  teeth  which  would  other- 
wise normally  align  themselves  in  the  arch.  Once  established,  the 
cheek  and  lip  pressure  maintains  the  inharmony  (Fig.  62). 

Angle  divides  all  irregularities  into  three  classes,  with  divisions 
and  subdivisions: 


THE  SECOND  DENTITION 


99 


Class  I. — The  first  molars  are  correctly  occluded  mesiodistally, 
the  teeth  anterior  being  in  malocclusion,  though  the  biscuspids  may 
be  in  correct  mesiodistal  relation. 

The  general  characteristic  of  the  class  is  that  shown  in  Fig.  58. 

Class  II. — The  lower  first  molars  occlude  distally  to  the  upper 
first  molars,  causing  retrusion  of  the  lower  jaw.  Division  I  is  char- 
acterized by  distal  occlusion  on  both  sides,  the  upper  arch  is  narrowed, 
the  upper  incisors  lengthened  and  protruded.  The  upper  lip  is  short 
and  functionless,  while  the  lower  lip  is  thickened  and  rests  cushion- 

FiG.  59 


Malocclusion.     Class  II.     (Angle.) 


like  between  the  upper  and  lower  incisors,  increasing  the  protrusion 
of  the  upper  and  the  retrusion  of  the  lower.  There  is  usually  mouth 
breathing,  due  to  some  form  of  nasal  obstruction. 

Division  I. — The  characteristic  exists  on  one  side  only,  the  other 
being  normal.    Mouth  breathing  is  usually  associated  (Fig.  59). 

Division  II. — There  is  distal  occlusion  on  both  sides,  but  the 
upper  incisors  are  retruded  instead  of  protruded,  with  crowding  in 
the  cuspid  region.  These  are  associated  with  normal  breathing 
(Fig.  60). 


100 


DENTITION 


Subdivision,  Division  II.— The  characteristic  is  upon  one  side 
only,  normal  breathers. 

Class  III  —Division  I.— In  this  class,  the  lower  first  molars  occlude 
mesially  to  the  upper  first  molars  on  both  sides,  and  the  lower  jaw 
progressively  protrudes  anteriorly  (Fig.  61). 


Fm.  60 


Malocclusion,     Class  II.     Division  II.     (Angle.) 

Subdivision,  Class  III.— The  mesial  occlusion  is  upon  one  side 
only,  the  other  being  normal,  the  arches  crossing  in  the  region  of  the 
incisors. 

Angle  has  formulated  the  law  "that  the  best  balance,  the  best 
harmony,  the  best  proportions  of  the  mouth  in  its  relations  to  the 
other  features  require  that  there  shall  be  the  full  complement  of 
teeth,  and  that  each  tooth  shall  be  made  to  occupy  its  normal 
occlusional  relations.     He  also  states  that  the  best  development  of 


THE  SECOND  DENTITION 


101 


the  bones  of  the  face  and  tliroat,  the  size  and  function  of  its  cavities 
are  dependent  upon  the  position  of  the  teeth. 


Fig.  61 


Malocclusion.     Class  III.     (Angle.) 


Fig.  62 


The  specific  causes  inducing  malocclusion  of  the  teeth  as  classi- 
fied above  are: 

1.  Premature  loss  of  deciduous  teeth  prevents  the  pressure  of  the 
first  molars  upon  the  teeth  anterior  to  them,  which  mechanically  aids 
in  the  development  of  the  jaws  and  thus  of  the  space  necessary  for 
accommodation  of  the  permanent  teeth.  It 
also  allows  the  first  molar  to  drift  forward  and 
come  into  malocclusion,  and  also  to  close  the 
space  occupied  by  the  deciduous  tooth,  thus 
lessening  space  for  its  successor  and  forcing  it 
into  buccal  or  lingual  displacement.  The  same 
is  true  of  loss  of  approximal  tooth  contact  as 
the  result  of  caries  (Fig.  62).  For  this  reason 
the  prophylaxis  of  orthodontia  demands  the 
retention  of  the  space  for  normal  eruption  of  the 
permanent  teeth  by  fillings  or  mechanical  devices 
if  necessary.  1 

2.  Prolonged  retention  of  deciduous  teeth  may  cause  a  deflection 
of  the  temporary  successor  or  prevent  its  eruption. 

3.  Through  loss  of  permanent  teeth  on  that  side  upon  which  the 
tooth  is  extracted,  the  development  of  the  jaw  will  be  prevented 


Effects  of  the  prema- 
ture loss  of  a  deciduous 
second  molar. 


1  For  the  prophylaxis  of  malocclusion  and  sequelae,  the  reader  is  referred  to  articles 
by  J.  Lowe  Young,  Dental  Cosmos,  October,  1815;  E.  A.  Boyne,  Dental  Digest,  1916, 
and  M.  T.  Watson,  Dental  Items  of  Interest,  April,  1916. 


102 


DENTITION 


and  the  tooth  posterior  to  the  space  will  tend  to  tip  or  drift  forward 
into  malocclusion. 

4.  Tardy  eruption  of  permanent  teeth  permits  closure  of  the  space 
altogether  or  in  part,  and  the  resistance  offered  causes  a  deflec- 
tion of  the  tardy  tooth  (Fig.  62).  The  total  absence  of  certain 
permanent  teeth  may  be  placed  under  this  heading. 

5.  Supernumerary  teeth,  by  occupying  space,  also  compel  the 
normal  teeth  to  take  an  abnorma,l  position,  and,  if  erupting  after 
them,  may  displace  them  by  constant  pressure  (Figs.  171  and  210). 


Fig.  63 


Fig.  64 


Case  of  adenoids.     Fig.  63,  before  operation;      Fig.  64,  after  operation.     (Faught.) 

6.  Habits  such  as  thumb  and  lip  sucking  or  lip  biting  will  move  the 
upper  anterior  teeth  outward  and  the  lower  anterior  teeth  inward. 
Holding  the  tongue  between  the  anterior  teeth  produces  infra- 
occlusion  of  the  anterior  teeth,  while  the  constantly  open  mouth  per- 
mits supra-occlusion  of  the  molars. 

7.  Nasal  obstructions  occurring  in  the  developing  child  produce 
mouth  breathing,  and  the  opening  of  the  mouth  causes  contraction 
of  the  muscles  upon  the  teeth  and  bones,  producing  abnormalities 
of  the  bone  of  the  jaw;  the  irregularity  of  Class  II  (Division  I),  an 
undeveloped  nose  and  adjacent  region  of  the  face.  Faught  has  ably 
illustrated  these  conditions  in  Figs.  63  to  71.^  The  consideration  of 
malocclusion  as  a  general  subject  is  properly  relegated  to  special 
works,  and  the  reader  is  referred  to  Angle's  Maloccliision  of  the  Teeth 
and  other  works  on  the  subject. 


1  Dental  Cosmos,  1908,  p.  7. 


The  se!cond  dentition 


103 


Disorders  of  the  Second  Dentition. — The  devitaUzation  of    the 
pulp  of  a  temporary  tooth  and  proper  canal  filling  delays,  but  does  not 


Fig.  66 


Diagrammatic  sagittal  section,  show- 
ing relation  of  anatomical  landmarks. 
(Faught.) 


Adenoid    vegetations.       Compare    Fig 
65.      (Faught.) 


Fig.  67 


Diagrammatic  coronal  section  through  head  in  the  region  of  the  first  molar, 
showing  nasal  septum,  uncinate  process,  inferior  meatus,  inferior  turbinates,  middle 
ethmoidal  cells,  middle  turbinates,  and  hiatus  semilunaris.     (Faught.) 

absolutely  prevent,  resorption.  Chronic  abscesses  upon  such  roots 
destroy  the  absorbent  organ,  but  some  pathological  resorption  may 
occur,  as  in  case  of  permanent  roots  (which  see).    Pus  has  an  alkaline 


104  DENTITION 

reaction  which  may  neutrahze  the  acid  solvent.  As  a  rule,  such  roots 
are  mechanical  obstructions  to  the  permanent  crowns,  which  are 
deflected  to  one  side  and  caused  to  erupt  irregularly;  again,  the 


Hypertrophy  of  right  inferior  turbinal,  also  deflected  septum  and  spur. 
Compare  Fig.  67.     (Faught.) 

temporary  root  may  be  bodily  pushed  aside,  its  apex  pressed  against 
the  alveolar  process  and  gum  tissue,  which  are  resorbed,  and  the 
necrotic  root  end  is  seen  extruded  through  the  gum.  Extraction  is 
indicated. 

Fig.  69 


Cystic  middle  turbinal,  hypertrophied  inferior  turbinals,   enlarged  middle    ethmoidal 
cells,  and  hypertrophied  middle  turbinal.     Compare  Fig.  67.      (Faught.) 

When  temporary  roots  are  not  thus  mechanically  removed  they  are 
gradually  extruded  and  decayed,  or  suppurative  processes  cause  the 
resorption  of  the  alveolar  process  about  them. 


THE  SECOND  DENTITION 


105 


Injudicious  retention  of  temporary  teeth  may  thus  cause  an  irregu- 
larity. On  the  other  hand,  premature  extraction  by  permitting  the 
approximation  of  the  previously  erupted  permanent  teeth  may  have 
an  equally  bad  effect  upon  an  erupting  tooth  (Fig.  62), 

In  anticipation  of  physiological  resorption  of  temporary  roots,  all 
temporary  teeth  should  be  carefully  watched,  cleansed,  filled,  and,  if 
necessary,  their  roots  treated  so  that  a  normal  replacement  by  the 
permanent  teeth  may  occur.  If  pronounced  disease  occur  just 
previous  to  the  time  for  normal  replacement,  extraction  is  indicated. 

Early  extraction  has  sometimes  caused  early  eruption  of  the  per- 
manent teeth,  e.  g.,  bicuspids  at  seven  years  of  age. 


Fig.  70 


Fig.  71 


H3T)ertrophied  posterior  end  of  inferior 
turbinal.     Compare  Fig.  65.    (Faught.) 


Nasal  polypi.     Compare  Fig.  65. 
(Faught.) 


It  will  be  recalled  that  the  teeth  are  an  evolution  of  the  dermoid 
system,  which  fact  possesses  pathological  significance  in  certain  acute, 
specific  skin  diseases.  It  is  noted  in  some  cases  of  the  eruptive 
fevers  of  children,  particularly  when  the  child  is  much  debilitated, 
that  after  the  cessation  of  the  acute  disease,  a  necrotic  affection  of 
the  jaw  occurs,  involving  the  alveolar  bone  and  its  contents.  As 
many  of  these  cases  occur  between  the  ages  of  three  and  seven  years, 
the  temporary  teeth  are  still  in  situ;  these,  with  the  partially  devel- 
oped permanent  teeth  and  the  enclosing  bone,  may  be  exfoliated. 
The  necrotic  process  may  involve  but  one  tooth,  or  may  include 


106  DENTITION 

all  of  the  temporary  teeth,  their  successors,  and  a  large  mass  of 
bone.^  The  disease  with  which  this  necrosis  is  most  frequently 
associated  is  scarlet  fever  j^  it  is  also  found  as  a  sequel  of  measles 
and  smallpox.  "The  cases  prior  to  exfoliation  of  the  bone,  exhibit 
a  stripping  of  the  periosteum,  apparently  beginning  about  the  necks 
of  the  teeth.  A  discharge  of  pus  having  a  fetid  odor  is  present,  and 
the  soft  tissues  may  be  raised  from  the  bone  for  a  variable  extent;" 
that  is,  there  is  evidence  of  purulent  periostitis.  In  the  course  of 
some  weeks,  six  or  eight,  the  necrotic  bone  and  its  contents  exfoliate, 
Salter  observes  that  the  sequestra  forming  after  severe  scarlet  fever 
are  much  more  extensive  than  those  which  form  as  a  sequel  of  measles. 
An  interesting  case  of  bilateral  sequestra  of  the  aveolar  process 
due  to  typhoid  fever  alone  is  reported  by  Cowper.^  Two  sound 
teeth  were  involved  in  each  sequestrum.     (Fig.  72.) 

Fig,  72 


Right.  Left. 

Labial  aspect  of  bilateral  sequestra  apparently  due  to  typhoid  fever  alone.     (Cowper.) 

The  administration  to  children,  of  mercurials,  has  caused  such  a 
loss  of  teeth  and  process.  I  have  seen  a  sequestrum  containing  three 
undecayed  teeth  attributed  to  this  cause,  and  others  have  been 
reported.  In  these  cases  the  parts  should  be  kept  as  aseptic  as 
possible  by  means  of  hydrogen  dioxid  and  the  compound  tincture 
of  capsicum  and  myrrh  (enough  to  cloud  a  glass  of  water),  used  as  a 
stimulant  mouth  wash.*  When  loose,  the  sequestrum  should  be 
removed.  The  parts  heal  by  granulation,  if  due  attention  be  paid 
to  the  general  physical  welfare  of  the  child. 

Eruption  of  the  Molars.— The  first  permanent  molars  rarely 
produce  more  than  slight  rheumatic  pains.  The  gum  irritation 
may  be  relieved  by  an  X-incision,  or  at  times  by  the  application 

1  Salter,  Dental  Pathology.  2  Ibid. 

3  Dental  Cosmos,  1909,  p.  765.  ^  Garretson,  A  System  of  Oral  Surgery, 


THE  SECOND  DENTITION  107 

of  phenol-sodique  and  laudanum,  equal  parts,  or  phenol  camphor, 
with  the  finger  tip.  A  little  alcohol  or  dilute  tincture  of  iodin  serves 
almost  equally  well. 

As  some  time  may  elapse  between  eruption  and  occlusion,  the  first 
molars  do  not  receive  a  proper  friction.  Associated  frequently  with 
carious  temporary  teeth,  they  are  frequently  decayed  in  their  sulci 
and  fissures;  to  prevent  this  it  has  been  recommended  that  oxy- 
phosphate  of  zinc  be  placed  over  these  fissures  without  previous 
excavation.^  The  oxyphosphate  of  zinc  or  copper  may  also  be  thus 
used  in  third  molars  which  are  even  more  liable  to  dental  caries. 

The  lower  second  molars  may  cause  some  irritation  owing  to  an 
insufficient  development  of  the  jaw  at  the  angle,  leaving  an  inade- 
quate accommodation  for  the  cro'^Ti.     At  about  nine  years  of  age 
the  second  molar  occupies  the  angle  of  the  jaw  in  much  the  same 
position  as  shown  in  Fig.  73  for  the  third  molar.    If  held  back,  a 
pathological  condition  equivalent  to  that  oc- 
curring in  the  temporary  teeth  may  result;  ^^°-  "^^ 
reflexes  producing  heavy  pains  about  the  jaw 
or  reflex  effects,  such  as  chorea,  may  be  pro- 
duced. 

Truman^  has  prevented  a  threatened 
second  attack  of  this  sort  by  deep  incisions 
in  the  gum  over  the  site  of  the  crown.  The 
presumption  is  that  such  treatment  relieves 
the  tension  upon   the   pulp  underlying  the 

J        1    „  •  J.  Condition  of  third  molar 

developmg  root.         _  _       _  ^,  ^^^^^^^  ^^^^^  ^^  ^^^_ 

Kirk^    calls    attention    to    the    liability    of       (Radiographed  by  Custer.) 

chorea  to  be  associated  with  reflexes  from  the 

dental  region  at  from  four  to  nine  years  of  age,  and  cites  a  case  from 
the  practice  of  C.  N.  Peirce  in  w^hich  choreic  manifestations  were 
permanently  relieved  by  the  removal  of  a  deciduous  molar  inter- 
fering with  the  eruption  of  its  permanent  successor,  the  bicuspid. 
He  also  cites  a  case  of  repeated  hysterical  manifestations,  following 
nervous  irritability  due  to  each  replacement  of  a  deciduous  tooth  by 
its  successor.  Flagg  cured  a  case  of  chorea  in  a  boy,  by  the  extrac- 
tion of  four  teeth  from  a  very  crowded  arch.* 

The  third  molars  frequently  induce  pathological  conditions. 

The  upper  third  molar,  meeting  in  its  descent  the  roots  of  the 
second  molar,  may  be  united  to  it  by  hj^ercementosis — ^the  condition 
of  concrescence  (which  see) ;  escaping  this,  it  may  meet  a  dense  palato- 
alveolar  plate  of  bone  at  the  tuberosity  and  be  deflected  buccally 

1  L.  Ashley  Faught.  ^  International  Dental  Journal,  1899. 

3  Dental  Cosmos,  1905.  ^  Private  communication. 


108  DENTITION 

through  the  thinner  buccal  plate  of  bone,  so  that  its  occlusal  face 
presents  cheekward  (Fig.  74).  Its  occlusal  face  may  present  more 
posteriorly  or  more  anteriorly.  Here  retained  food  collects  about 
it  and  caries  occurs,  or  a  suppurative  inflammation  of  the  cheek 
or  free  gum  margin  may  occur.  For  this  condition  sterilization,  free 
incision  of  the  gum  margin,  and  subsequent  asepsis  maintained  by 
antiseptic  sprays  will  reduce  the  inflammation,  which,  however,  is 
apt  to  recur  at  intervals.  If  the  cheek  be  irritated  or  the  position  of 
the  tooth  permanently  fixed,  only  traction  of  the  tooth  into  a  correct 
position,  grinding  away  of  the  sharp  cusps,  or  extraction  will  alle- 
viate the  condition.  The  extraction  of  such  a  tooth  is  little  loss  to  the 
individual.  A  bit  of  cotton  saturated  with  a  mild  antiseptic  may 
be  placed  between  the  tooth  and  cheek  for  a  time  after  grinding. 
The  possibility  of  concrescence  in  such  a  case,  as  shown  in  Fig.  74, 
must  be  considered  when  extraction  is  intended.    Individual  motion 

Fig.  74  Fig.  75 


Abnormal  eruption  of  the  upper  third  Partial  eruption  and  impaction  of  third 

molar.  molar.     (Radiograph  by  Custer.) 

is  diagnostic  of  separate  teeth,  and  is  readily  induced,  when  the 
crowns  are  together,  by  pressing  a  strong,  thin,  flat-bladed  instru- 
ment between  the  teeth  and  turning  it.  The  teeth  are  seen  to  move 
apart. 

The  pressure  of  an  erupting  third  molar  upon  the  second  molar 
may  cause  neuralgic  pains,  and  at  times  the  teeth  in  general,  as  far 
forward  as  the  central  incisor,  may  seem  to  loosen  up  and  become 
tender  to  touch  and  again  become  comfortable  and  tight.  These 
symptoms  may  be  repeated  apparently  in  consonance  with  the  efforts 
at  eruption.  This  pressure  also  causes  irregularities  of  alignment 
or  breaks  up  an  orthodontia.  Their  extraction  for  this  reason  is 
sometimes  indicated.  The  third  upper  molar  may  be  impacted  with 
its  face  inclined  toward  the  second  molar  root  and  may  cause  resorp- 
tion.    (See  Impaction.) 

Owmg  to  insufficient  development  at  the  angle  of  the  jaw,  or 
density  of  the  bony  capsule  due  to  chronic  mild  irritation  from  any 


THE  SECOND  DENTITION  109 

cause  or  some  malposition  of  the  tooth  itself,  lack  of  room  due  to  a 
general  malocclusion  from  any  cause  or  perhaps  to  some  malnutri- 
tional  condition  in  the  patient — singly  or  combined — it  is  almost  the 
rule  that  the  eruption  of  the  lower  third  molar  is  attended  with  some 
degree  of  discomfort  due  to  gum  and  bone  irritation,  and,  possibly, 
to  pressure  on  the  formative  pulp  (Fig.  73). 

For  some  months  prior  to  eruption,  heavy,  gnawing,  rheumatic 
pains  may  be  indefinitely  located  about  the  jaw  and  ear  of  the 
affected  side.  The  muscles  of  mastication  become  stiff  and  may 
contract  spasmodically,  simulating  trismus.  These  symptoms,  if 
severe,  may  be  relieved  by  deep  X-incisions  in  the  gum ;  or,  if  mild, 
by  the  application  of  non-discoloring  rubefacients  or  sedatives  to 
the  outside  of  the  face,  over  the  affected  parts.  The  massage  of  the 
parts  affords  some  relief.    Flagg  recommended  the  following : 

I^ — Tinct.  opii, 

Tinct.  aconiti, 

Chloroformi p.  aeq. — M. 

Sig. — To  be  rubbed  on  the  outside  of  the  face. 

Or, 

I^ — Aconitinae gr.  ij 

Cerati  simplicis 3J — M. 

Sig. — To  be  well  spatulated.  To  be  distended  with  oil  of  cloves  or  phenol 
camphor  and  gently  rubbed  on  the  outside  of  the  face,  the  mouth  and  eyes  to  be 
particularly  avoided. 

Or,  when  the  aconitine  fails  to  produce  relief: 

I^ — Veratrinae gr.  xx 

Cerati  simpUcis 5J — M. 

Sig. — To  be  used  in  the  same  manner  as  the  aconitine. 

As  the  tooth  advances,  the  s^Tnptoms  may  become  progressively 
severe.  The  gum  may  become  inflamed,  swollen,  and  be  masticated 
upon,  the  oral  pyogenic  organisms  produce  infection,  presumably 
finding  an  entrance  at  the  point  proximating  the  second  molar.  The 
patient  suffers  from  the  pain  and  inability  to  masticate  and  swallow, 
and  becomes  nervous,  irritable,  and  debilitated;  the  breath  becomes 
fetid  and  the  salivation  excessive.  The  inflammation  extends  into 
the  contiguous  tissues,  and  pus  may  form,  extending  into  them; 
swelling  may  occur  in  the  adjacent  glands,  parotid,  submaxillary,  etc. 
It  may  also  extend  to  the  tonsil  or  pharynx.  All  mastication  is  pre- 
vented, fever  is  present,  and  the  patient  prostrated;  septicemia  and 
death  may  follow.^  Reflex  pains  may  occur.  Neuralgia  and  even 
nervous  and  mental  disturbances  may  occur  (see  page  72).  Brown^ 
relates  a  case  of  noma  which  developed  from  an  infection  in  this 

'  Flagg,  and  occasional  reports.  *  Dental  Cosmos,  1908,  p.  5. 


no  DENTITION 

location.    The  gangrenous  condition  extended  to  the  lungs.    Death 
ensued. 

Brown  also  calls  attention  to  cases  of  cancer  diagnosed  as  patho- 
logical eruption.  Perhaps  private  practice  is  more  immune  but  I 
have  never  had  such  a  development  either  privately  or  in  clinical 
experience. 

Results  similar  to  these  may  occur  when  the  crown  is  partly 
erupted,  being  covered  at  its  distal  portion  by  a  curtain  of  gum 
which  may  be  ulcerated  upon  its  under  surface.  This  curtain  of 
gum  may  be  thin  and  stretched,  or  project  rather  rigidly  over  the 
tooth  without  stretching,  as  though  attached  to  it,  sometimes  a  strap 
of  gum  crosses  the  tooth  crown. 

In  these  latter  cases  the  pus,  as  a  rule,  finds  egress,  but  occasionally 
it  burrows  into  the  pocket  between  the  tooth  and  contiguous  tissue, 
causing  much  inflammation  or  pus  formation  w^hich  may  invade  the 
cheek  muscles  or  involve  the  inferior  dental  canals.  When  gum 
pockets  remain  about  teeth,  food  may  ferment  in  them  and  cause 
deep  pus  formations  which  may  result  in  Ludwig's  angina,  a  frequently 
fatal  disease.     (See  Ludwig's  Angina.) 

In  some  case  necrosis  may  ensue.  Fortunately  untoward  experi- 
ence is  rather  rare,  most  cases  responding  to  proper  treatment.  Other 
phases  of  pathological  eruption  of  third  molars  will  be  considered 
under  impactions. 

Treatment. — The  treatment  depends  upon  the  stage  to  which  the 
inflammation  has  advanced  and  the  position  of  the  tooth. 

In  cases  more  particularly  due  to  gum  infection  and  inflammation 
rather  than  impaction,  if  the  patient  be  able  to  partly  open  the 
mouth,  the  part  may  be  sterilized  by  spraying  it  with  a  germicide 
such  as  a  1  to  2000  solution  of  mercuric  chloride  in  hydrogen  dioxid 
(or  hot  carbolized  water,  follow^ed  by  application  of  tincture  of  iodin 
(Brown)  or  by  injecting  iodin  trichlorid,  1  to  100) .  (See  Index.)  Fol- 
lowing this  an  injection  of  novocain  solution  is  made  into  the  flap 
of  tissue,  or  a  conductive  anesthesia  done  and  the  gum  completely 
removed  from  over  the  face  of  the  crown,  or,  if  feasible,  any  pocket 
wall  cut  away. 

To  accomplish  this,  a  deep  linear  cut  is  made  with  a  sharp  bistoury, 
extending  from  the  distolingual  to  the  mesolingual  angle  of  the 
crown,  if  it  need  go  that  far.  A  similar  cut  is  made  from  the  disto- 
buccal  to  the  mesobuccal  angle.  If  not  already  free,  the  gum  is 
divided  at  its  mesial  contact  with  the  distal  surface  of  the  second 
molar.  The  block  is  now  penetrated  by  a  tenaculum,  drawn  tense, 
and  the  final  cut  made  at  the  distal  border  with  decidedly  curved 
gum  scissors.    Less  cutting  is  required  in  some  cases.    A  special  gum 


THE  SECOND  DENTITION  111 

guillotine  is  obtainable,  which  practicall}^  bites  out  a  piece  of  the 

gum  flap  (Fig.  76).     Its  use  is  limited  to  simple  flaps.    The  electric 

cautery  may  be  used  to  burn  away  the  gum  tissue.    Even  without 

anesthesia  a  white  hot  cautery  is  not  very  painful  and  eliminates 

bleeding. 

Fig.  76 


Ash's  gum  guillotine. 

The  hydrogen  dioxid  spray  should  be  again  applied  to  remove  any 
possible  pus  germs  present,  and  should  be  repeated  at  intervals  of 
about  two  hours;  any  pus  pocket  should  be  thoroughly  flushed.  Tinc- 
ture of  iodin,  diluted  about  one-half  with  alcohol,  may  be  applied 
every  few  hours  or  much  oftener  b}'  means  of  cotton  wound  on  an 
applicator  or  tooth  pick,  and  exerts  a  germicidal  effect.    A  1  to  1000 

Fig.  77 


Gum  scissors. 

iodin  trichlorid  wash  for  a  time  as  recommended  by  Wass  may  be 
used  (see  Index).  A  neglect  of  antisepsis  gave  the  editor  a  week  of 
personal  discomfort  and  inability  to  masticate,  after  the  removal  of 
a  trifling  and  apparently  non-inflamed  flap  of  gum.  A  cold  compress 
should  be  recommended  for  the  angle  of  the  jaw,  if  deemed  advisable. 
Magnesium  sulphate  as  a  derivative  may  be  used  with  advantage. 
If  the  patient  be  confined  to  his  bed  and  unable  to  open  the  jaws, 


112  DENTITION 

a  more  difficult  operation  presents.  The  first  object  should  be  to 
reduce  the  intensity  of  the  inflammatory  symptoms.  This  is  accom- 
plished by  the  removal  of  the  gum  block  as  above,  if  the  mouth  can 
be  opened  sufficiently.  Anesthesia  may  be  resorted  to,  after  oral 
sterilization,  for  the  purpose.  A  jaw  separator  is  introduced,  and 
operated  until  sufficient  space  is  gained  and  the  cuts  made.  If  no 
more  be  possible  at  the  first  visit,  the  lingual  and  buccal  linear  cuts 
should  be  made  to  insure  free  bloodletting,  which  may  be  increased 
by  syringing  forcibly  with  lukewarm  water,  the  position  of  the 
patient  being  such  that  gravity  favors  its  flowing  out  of  the  mouth. 

Cold  compresses  are  to  be  placed  over  the  angle  of  the  jaw  and 
magnesium  sulphate  and  the  hot  pediluvium  administered  as  deriva- 
tives. Cataplasma  kaolini,  a  compound  of  kaolin  (Chinese  clay), 
boric  acid,  methyl  salicylate,  glj^cerin,  and  small  quantities  of  thymol 
and  oil  of  peppermint,^  is  useful,  applied  in  quantity  to  the  face, 
externally.    The  antiseptic  sprays  are  to  be  used  as  before  directed. 

If,  in  addition,  local  massage  or  the  heat  of  a  100  candle  lamp,  and 
massage  over  the  angle  of  the  jaw  be  practised,  the  swelling  and 
muscular  hardness  usually  disappear  in  a  few  days.  It  is  well  to 
then  remove  the  entire  block  of  gum  to  prevent  reinfection.  There 
can  be  no  question  that  complete  anesthesia  and  thorough  gum 
block  removal,  at  the  first  visit,  is  the  most  advisable  surgery. 

In  case  of  suppuration  deep  in  tissues  iodin  trichlorid  as  an  injec- 
tion, 1  to  100,  and,  as  a  wash,  1  to  1000  (see  Index)  may  be  used  and 
injections  of  a  staphylococcus  and  streptococcus  stock  vaccine  made 
hypodermically  as  suggested  by  Medalia.-     (See  Vaccine.) 

If  the  third  molar  be  correctly  placed,  its  eruption,  as  a  rule, 
proceeds  uninterruptedly  from  this  point,  though  it  may  never  be 
entirely  free  from  some  degree  of  overlapping  by  the  gum  tissue, 
owing  to  arrest  of  eruption  by  the  occlusion  of  the  more  advanced 
upper  third  molar.  Pockets  are  thus  formed  which  favor  food 
retention,  which,  undergoing  fermentation,  may  either  cause  ulcera- 
tion of  the  soft  parts,  or  caries  of  the  distal  and  distobuccal  surfaces 
of  the  tooth.  If  it  be  the  cheek  tissue  that  persistently  overlaps, 
the  tooth  should  be  removed,  but  inflammation  may  temporarily 
be  relieved  by  the  above  irrigation,  and  a  pellet  of  cotton  saturated 
with  eugenol  introduced  for  a  short  time.  Grinding  the  occlusal 
face  of  the  upper  molar  may  assist  eruption  of  the  lower. 

More  marked  malposition  may  cause  difficulty  of  eruption, 
necessitating  the  extraction  of  the  third  molar  or  even  of  the  second 
molar  in  order  to  let  it  erupt  or  in  order  to  reach  it.    In  some  cases 

1  Antiphlogistin  is  the  proprietary  equivalent. 

2  Dental  Cosmos,  January,  1914. 


THE  SECOND  DENTITION  113 

it  may  be  better  to  also  extract  the  upper  third  molar,  as  it  will 
probably  elongate  in  time  and  allow  food  to  pack  into  the  interspace 
mesial  to  it.  A  presentation  of  the  occlusal  face  of  the  third  molar 
to  the  distal  surface  of  the  second  molar  is  a  common  form  of  mal- 
position.    (Fig.  75.) 

The  third  molar  may  at  times  be  diagnosed  in  this  position  by 
passing  an  explorer  or  thin  right-angled  blade  down  the  distal  sur- 
face of  the  second  molar,  or  by  means  of  a  deep  incision  with  a 
bistoury  or  exploring  needle.  Failing  this,  or  preferably,  replacing 
it,  radiography  is  a  very  valuable  means  of  diagnosis.  Extraction 
of  the  third  molar  is  indicated. 

Fig.  7S 


The  beaks  of  these  forceps  have  been  ground  out  so  that  they  are  similar  to  those 
of  the  "Kells"  forceps.  The  bulge  of  the  crown  fits  into  the  hollow  beak  so  that  the 
beak  does  not  slip  oS.     (Kells,  Dental  Cosmos.) 

Kells^  cuts  the  occlusal  half  off  partly  with  a  small  diamond  or 
carborimdum  disk  and  saws  the  balance  off  with  a  dentate  bur  of 
extra  length  in  the  contra  angle  hand  piece.  The  remainder  of  the 
crown  is  grasped  with  a  right-angled  Ash  root  forceps  with  beaks 
hollowed  out.  It  is  pulled  forward.  In  all  cases  without  special 
necessity  for  packing,  U'rigation  with  salt  solution  and  the  induction 
of  a  good  clot  is  the  best  treatment.  Extraction  in  such  a  case  must 
be  carefully  done.  The  use  of  the  elevator  is  dangerous,  as  there  is 
danger  of  fractm^e  of  the  ramus,  which  has  occurred.     (Schamberg.) 

In  some  cases  a  portion  of  the  coronoid  process  should  be  removed 
to  make  a  path  for  easy  removal  of  the  tooth. 

Deeply  seated  in  this  situation,  pathological  resorption  of  the  root 
of  the  second  molar  may  result,  and  irritation  of  its  pulp  be  added 

1  Johnson's  Text-book  of  Operative  Dentistry. 


114  DENTITION 

as  a  complication.  In  this  case  the  second  molar  must  be  extracted 
and  if  not  producing  further  ill  results  the  third  molar  allowed  to 
erupt  as  possibly  useful.  (See  Malposition.)  The  alternative  is 
the  surgical  removal  of  a  portion  of  the  coronoid  process  before 
removing  the  third  molar. 

A  more  common  form  of  presentation  exhibits  the  distal  surface 
of  the  crown  above  the  gum  and  the  meso-occlusal  angle  locked 
beneath  the  cervix  of  the  second  molar  (Fig.  73).  Caries  is  not  in- 
frequently induced  by  the  retention  of  food.  The  third  molar  may  be 
removed  by  first  cutting  away  the  mesial  obstructing  portion  and 
then  lifting  out  with  the  forceps. 

Dr.  George  B.  Winters  is  said  to  have  demonstrated  a  successful 
technic  for  prompt  removal  of  impacted  lower  third  molars.  I  have 
solicited  this  but  he  prefers  to  delay  publication  to  a  later  date. 

The  operation  is  best  done  under  conductive  anesthesia.   (Index.) 

In  view  of  applied  therapy  it  is  well  to  remember  that  if  a  first 
molar  be  extracted  before  ten  years  of  age  the  second  molar  will 
usually  press  forward  into  the  place  of  the  first  and  assume  good 
alignment  and  occlusion.  Likewise  if  the  second  molar  be  extracted 
early,  the  third  will  come  into  its  place.  The  fact  is  valuable  when 
decision  must  be  made  as  to  retention  or  extraction  of  diseased 
molars.  Therefore  after  radiograph}^  to  ascertain  the  presence  of  a 
worthy  successor  extraction  at  proper  age  may  be  advisable. 

The  writer  had  a  patient  fifteen  years  of  age  with  a  badly  decayed 
second  molar  with  the  pulp  irritable.  This  was  a  good  case  for 
application  of  the  principle,  as  the  second  molar  roots  were  incom- 
plete at  this  age. 


CHAPTER   IV. 
MALPOSITION  AND  IMPACTION  OF  TEETH. 

MALPOSITION  OF  TEETH. 

A  TOOTH  is  malposed  when  out  of  its  normal  position  and  occlusion, 
though  in  some  cases  it  may  be  in  almost  normal  relation  to  its  ad- 
joining teeth. 

The  causes  have  been  discussed  in  the  chapter  on  Pathological 
Dentition,  page  94. 

Fig.  79 


Case  of  seven  lower  bicuspids,  two  supernumeraries  in  place  and  one  erupting.  This 
patient  has  two  supernumerary  upper  central  incisors  displacing  the  centrals  proper, 
yet  closely  resembling  them.  Dr.  Alfred  Haas  has  shown  me  a  similar  model  of  a 
lower  jaw  with  seven  erupted  bicuspids  from  which  he  already  had  extracted  an  eighth. 


Malpositions  which  are  remediable  through  the  application  of 
mechanical  force,  applied  by  means  of  suitable  apparatus,  belong  to 
operative  dentistry.  They  are  fully  treated  of  in  works  upon  opera- 
tive dentistry  and  orthodontia. 

The  extraction  of  teeth  after  they  have  been  erupted,  or  of  their 
predecessors,  is  one  of  the  most  frequent  causes  of  acquired  mal- 
position of  the  remaining  teeth.    The  teeth  move  from  their  original 

(115) 


116 


MALPOSITION  AND  IMPACTION  OF  TEETH 


Fig.  80 


positions,  the  anterior  teeth,  incisors,  laterals,  cuspids,  and  occa- 
sionally the  bicuspids,  having  a  tendency  to  drift  posteriorly,  some- 
times opening  a  space  between  the  central  in- 
cisors, sufficiently  large  to  create  a  deformity. 
The  molars  have  a  decided  natural  tendency 
to  drift  forward,  and  when  the  bicuspids  are 
removed  they  tip  anteriorly,  causing  maloc- 
clusion upon  their  distal  cusps  and  sometimes 
their  distobuccal  cusps  alone,  with  a  further 
tendency  to  tip  forward  and  sometimes  inward 
or  outward  as  well.  Separation  of  the  posterior 
teeth  may  occur,  and  in  any  event,  the  loss  of 
mesial  or  distal  support  permits  fibrous  food  to 
be  packed  between  the  teeth:  as  they  spring 
slightly  apart,  it  is  held  by  their  springing 
together  again.  The  lack  of  occlusion  brought 
about  by  extraction  of  antagonists  permits 
elongation,  and  the  loss  of  posterior  support  is  apt  to  bring  about 
labial  protrusion  or  abrasion  of  upper  anterior  teeth. 

Fig.  81  illustrates  a  case  of  malposition  of  molar  germs  which  have 
developed  in  the  incisal  region,  displacing  the  incisors. 


Effects  of  premature 
loss  of  permanent  first 
molars. 


Fig.  81 


Malposition  of  molar  teeth. 

IMPACTED  AND  ENCYSTED  TEETH. 

The  extreme  extent  of  dental  malposition  is  reached  when  the  per- 
manent teeth  do  not  erupt  at  all.  Instead  of  presenting  in  the  dental 
arch,  they  may  be_entirely  embedded  in  the  substance  of  the  bone. 


IMPACTED  AND  ENCYSTED  TEETH  117 

either  remaining  there,  with  or  without  pathological  manifestations,  or 
erupting  m  some  unusual  situation.  In  other  cases,  a  distinct  cystic 
tiunor  forms  about  the  enclosed  tooth  (Fig.  82).  The  cause  of  im- 
paction probably  lies  either  m  a  previous  malposition  of  other  teeth 
preventing  advance,  or  in  an  originally  malposed  tooth  germ,  or  to 
the  development  of  the  root  while  the  cro\\'n  advance  is  retarded,  the 
expulsive  force  of  root  formation  being  lost,  or  to  bone  condensation 
due  to  the  stimulation  from  the  effort  at  eruption  or  to  other  inflam- 
mation about  adjoining  teeth;  to  contracted  arches  due  to  mouth 
breathing  or  retarded  jaw  development  and  to  acute  infectious 
fevers  causing  inflammation  of  the  bone.  In  many  cases  orthodontic 
procedures  creating  room  may  permit  the  descent  of  the  tooth. 

Fig.  82 


Cyst  of  the  lower  jaw,  having  its  origin  about  an  undeveloped  tooth.      (Garretson.) 

Impacted  Lower  Third  Molars. — By  far  the  most  common  dental 
impaction  is  that  of  the  lower  third  molar.  The  extent  of  impaction 
varies  from  a  partial  eruption,  or  partial  imprisonment  of  the  tooth  by 
its  bony  surroundings,  to  its  entire  imprisonment  in  any  part  of  the 
ramus.  Many  of  the  more  severe  cases  treated  under  the  head  of 
pathological  dentition,  if  unrelieved,  would  be  included  in  the  category 
of  impacted  teeth. 

Feldman^  cites  a  case  of  impaction  of  a  right  lower  third  molar 
with  miformed  roots  and  associated  with  suppurative  swelling,  trismus 
and  glandular  enlargement. 

1  Dental  Cosmos,  1918,  p.  51. 


lis 


MALPOSITION  AND  IMPACTION  OF  TEETH 


In  Fig.  S3  is  shown  a  lower  third  molar  presenting  the  effects  of 
a  previous  impaction.     The  irritation  caused  by  the  efforts  of  the 


Fig.  83 


Right  half  of  lower  jaw,  showing  an  impacted  third  molar.    (Cryer.) 
Fig.  84 


Inner  side  of  left  half  of  same  lower  jaw.     (Cryer.) 

tooth  to  disengage  itself,  or  to  overcome  the  resistance  to  its  erup- 
tion  has  caused  an  active  formative  reaction  in  the  pericementum 
resulting  m  a  hypertrophy  of  the  cementum.     Likewise  the  pressure 


IMPACTED  AND  ENCYSTED  TEETH  119 

upon  the  bone  causes  a  condensing  osteitis,  and  the  bone  becomes 
dense,  more  obstructive,  and  less  vascular  (see  p.  49). 

If  the  distance  between  the  posterior  surface  of  the  second  molar 
and  the  columns  of  the  coronoid  process  be  very  short,  it  is  evident 


Fig 


Impaction  of  lower  third  molar.     Resorption  of  root  of  second  molar  and  impingement 
of  root  upon  inferior  dental  canal,  which  is  deflected  out  of  its  course.     (Cryer.) 

that  upward  eruption  is  impossible,  so  that  the  tooth  may  assume 
any  direction  of  movement,  the  most  common  being  forward,  the 
axis  of  the  tooth  changing  its  position  until  the  tooth  may  lie  in  a 
horizontal  position  or  even  become  inverted. 

Fig.  86  Fig.  87 


Impacted  lower  third  molar  beneath  gum.         Impacted  cuspid.     (Radigraph  by  E. 
Second  molar  tipped  forward.  (Radiograph  Ballard  Lodge.) 

by  E.  Ballard  Lodge.) 

Fig.  84  is  taken  from  the  same  jaw  as  Fig.  83,  but  shows  the 
opposite  side;  the  impaction  is  pronounced.  Fig.  85  shows  another 
case  with  different  anatomical  surroundings.    In  the  first  case  there 


120 


MALPOSITION  AND  IMPACTION  OF  TEETH 


were  evidences,  both  in  the  tooth,  in  its  bony  surroundings,  and  in 
the  external  cortical  bone,  of  the  results  of  the  irritation  produced 


Fig.  88 


Impacted  bicuspid.    (Radiograph  by  E.  Ballard  Lodge.) 

by  the  efforts  at  eruption.    The  cementum  was  thickened;  the  outer 
follicular  wall,  the  tissue  designed  to  form  the  alveolar  periosteum, 


Fig.  89 


Same  as  shown  in  Fig.  84,  with  tooth  removed.     (Cryer.) 

had  exercised  its  formative  osteogenetic  function,  and  a  capsule  of 
bone  had  formed  about  the  tooth;  it  lay  in  a  bony  chamber.    The 


IMPACTED  AND  ENCYSTED  TEETH 


121 


pressure  exerted  upon  the  distal  wall  of  the  second  molar  had  resulted 
in  a  pressure  resorption  of  its  root  until  the  pulp  chamber  was 
encroached  upon.    These  were  both  postmortem  cases,  and  no  records 


Fig.  90 


Wisdom  teeth  embedded  in  the  rami  of  the  lower  jaw.     (Tomes.) 

of  their  clinical  histories  were  obtainable.    The  symptoms  produced 

could  only  be  surmised  by  the  nature  of  the  anatomical  relations 

and  the  pathological  evidences.    There  may  have  been  a  prolonged 

but  mild  periostitis,  probably  a 

continued  pulp  irritation;  and  in  ^^^-  ^^ 

the  last,  neuralgia  of  any  grade 

of  severity.    The  pressure  upon 

nerves  of  the  inferior  dental  canal 

would  account  for  neuralgia   or 

mental  or  other  disturbance. 

Cryer  calls  attention  to  the 
fact  that  a  third  lower  molar  in 
its  attempt  to  erupt,  frequently 
causes  a  cellulitis,  extending  into 
the  temporomandibular  joint, 
causing  acute  ankylosis.^ 

Instead  of  remaining  in  the 
alveolar  portion  of  the  bone, 
the  impacted  tooth  may  come, 
to  occupy  a  cavity  in  some  por- 
tion of  the  body  or  the  ramus 
of  the  bone  (Figs.  91  and  92). 
The    positions  of    the    teeth    in 

such  cases  tend  to  confirm  Tomes 's  theory  of  the  development  of 
the  jaw.    The   jaw  being  lengthened,  and  the  ramus   developing 


Wisdom  tooth  buried  in  the  ramus. 
(Tomes,  after  Marshall.) 


1  Dental  Cosmos,  October,  1911. 


122  MALPOSITION  AND  IMPACTION  OF  TEETH 

through  conjoined  deposition  and  resorption  of  bone,  the  crown 
of  the  tooth  appears  to  be  either  fixed  in  a  bony  nucleus  and  trans- 
ported to  some  distant  point  in  the  developmental  progress  of  the 
jaw,  or  to  be  irregularly  shifted  about  during  jaw  growth.  At  later 
periods,  the  pressure  exercised  by  root  formation  disturbs  the  rela- 
tions of  the  tooth  with  its  earlier  surroundings.  These  efforts  at 
eruption  may,  at  late  periods,  cause  the  appearance  of  the  tooth  in 
odd  situations.  In  the  case  shown  in  Fig.  92  the  crown  of  the 
tooth  made  its  way  through  the  angle  of  the  bone  and  through  the 
muscles  and  skin.  The  opening  in  the  skin  healed  upon  extraction 
of  the  tooth. 

Impacted  Upper  Third  Molars. — Some  phases  of  impaction  of  this 
tooth  have  been  spoken  of  under  the  head  of  Pathological  Dentition. 
The  most  common  is  imprisonment  of  the  tooth  and  its  subsequent 
partial  eruption  in  a  horizontal  position,  the  crown  pointing  toward 

Fig.  92 


From  a  wax  model  in  the  museum  of  the  London  Odontological  Society.    (Tomes.) 

the  cheek  (Fig.  74).  The  crown  of  this  tooth  may,  in  rare  cases,  be 
directed  inward  or  backward,  in  the  latter  case  being  arrested  by 
the  pterygoid  plates  of  the  sphenoid  bone.  It  may  present  with 
an  anterobuccal  facing  of  the  crown,  as  shown  in  Fig.  93,  or  with 
a  posterobuccal  facing. 

In  a  case  recorded  by  Tomes  (Fig.  94)  the  extraction  of  the 
second  molar  revealed  the  third  molar  in  a  reversed  position,  its 
roots  occupying  the  depression  between  the  roots  of  the  second 
molar.  A  case  has  been  reported,  of  an  upper  molar  with  the  roots 
partly  embedded  in  the  floor  of  the  antrum,  its  neck  carious,^  and 
the  antrum  in  a  state  of  suppuration.  The  upper  third  molar  is 
liable  to  be  joined  to  the  second  molar  by  concrescence  (q.  v.)  and 
its  descent  prevented. 

1  Possibly  resorbed  or  decalcified  instead  of  carious. 


IMPACTED  AND  ENCYSTED   TEETH 


123 


Impacted  Cuspids. — In  point  of  frequency  of  impaction  the  upper 
cuspids  stand  next  to  the  lower  third  molars.  The  upper  cuspids  lie 
high  up ;  the  floors  of  their  crypts,  in  which  they  lie  loosely,  are  at  a 
higher  level  than  those  of  the  adjoining  teeth;  their  crowns,  as  with 
the  other  anterior  teeth,  lie  lingual  to  the  roots  of  their  predecessors. 
All  of  these  are  elements  which  might  cause  displacement  of  the 
developing  cuspids.  Should  the  advance  of  eruption  not  keep  pace 
with  the  development  of  the  alveolar  bone,  imprisonment  is  likely; 
again,  the  dense  bone  immediately  about  the  first  bicuspid  and 
lateral  incisor  may  offer  a  deflecting  resistance.     Examining  the 

texture  of  the  bone  about  these 
F^°-  ^^  parts,    it   is   evident  that   the 

direction  of  least  resistance  to 
the  advance  of  a  much  deflected 
crown   is   into  the    cancellated 

Fig.  94 


Upper  jaw,  with  the  third  molar  directed 
forward  and  impinging  upon  the  second 
molar.  The  small  tooth  situated  high  up 
in  the  anterior  part  of  the  jaw  was  forced 
there  by  the  spade  of  the  grave-digger. 
The  artist's  accuracy  in  delineating  all 
parts  of  the  specimen  has  rendered  this 
explanation  necessarj'.     (Tomes.) 


A  second  molar  of  the  upper  jaw 
with  the  wisdom  tooth  inverted  and 
embraced  mthin  the  roots.      (Tomes.) 


bone  of  the  incisor  portion  of  the  alveolar  process;  hence  it  is  most 
usual  to  find  the  crowns  of  these  teeth  lying  with  their  cusps 
pointing  forward  (Fig.  95).  Several  recorded  cases  have  the  posi- 
tions shown ;  one  or  both  of  the  teeth  may  be  impacted.  Cuspid  teeth 
may  erupt  into  the  nasal  cavity  or  appear  in  the  canine  fossa,  and  pre- 
sent the  crowns  cheekwise,  or  lie  horizontally  and  above  the  roots  of 
the  bicuspids. 

Glas,  of  Vienna,  discovered  a  cuspid  in  the  nasal  floor  associated 
with  calcic  formations  in  its  ulcerated  surface  (rhinolith).  The 
patient,  aged  nineteen  years,  had  frequent  fetid  eructations,  with 
vomiting  of  green,  foul-smelling  masses.  With  the  removal  of  the 
cuspid  the  vomiting,  etc.,  ceased. 

A  case  of  similar  character  producing  antral  empyema  and  a  fistula 
upon  the  gum  was  due  to  an  impacted  supernumerary  tooth.^ 


1  Crandall,  Dental  Cosmos,  May,  1914. 


124 


MALPOSITION  AND  IMPACTION  OP  TEETH 


Impaction  of  Other  Teeth. — While  impactions  are  most  common  in 
connection  with  the  teeth  named,  any  other  teeth  of  a  denture  may 
be  imprisoned.     Fig.  96  shows    an  impacted    bicuspid  whose  root 


Fig.  95 


Abnormal  jaw,  showing  impacted  cuspids.     (Cryer.) 
Fig.  96 


Impacted  bicuspid.    (Salter.) 


development  has  been  normal  as  regards  its  length,  but  whose  curve, 
has  been  modified  by  the  resistance  of  surrounding  tissues.  Fig.  98 
exhibits  an   imprisoned  central  incisor,   whose  retention  was,   no 


IMPACTED  AND  ENCYSTED  TEETH 
Fig.  97 


125 


Lower  maxilla,  in  which  the  right  second  bicuspid  is  placed  obliquely,  the  root  being 
directed  backward.  The  crown,  though  exposed,  does  not  rise  above  the  level  of  the 
alveolar  margin.     (Tomes.) 

Fig.  98 


Imprisoned  central  incisor.      (Kirk  and  Cryer.) 
Fig.  99 


Maxilla,  in  which  the  temporary  cuspids  (the  sockets  of  which  are  shown  by  the 
dotted  lines)  were  retained,  and  the  permanent  canines  developed  within  the  substance 
of  the  jaw.  The  bone  has  been  removed  on  the  one  side  to  show  the  direction  taken 
by  the  tooth,  which  has  been  twisted  on  its  axis  to  the  extent  of  a  quarter  of  a  turn. 
(Tomes.) 


126  MALPOSITION  AND  IMPACTION  OF  TEETH 

doubt,  determined  and  malposition  caused  by  the  development  and 
presence  of  the  brood  of  supernumerary  teeth  which  surrounded  its 
crown. 

Upper  incisor  teeth  have  been  seen  inverted  and  their  crowns 
erupted  into  the  nasal  cavity,  where  they  have  produced  inflammation, 
which  later  became  infective.^  A  supernumerary  tooth  has  been 
found  in  the  floor  of  the  nasal  cavity^  so  that  presence  of  all  normal 
teeth  should  not  exclude  extra  teeth  from  consideration  in  making 
a  diagnosis.  Radiography  may  demonstrate  an  unsuspected  super- 
numerary. 

Impacted  teeth  do  not  necessarily  produce  such  pathological  con- 
ditions as  produce  untoward  symptoms.     The  malposition  of  the 
impacted  teeth  either  in  total  or  partial  impaction  may,  however, 
lead  to  malposition  of  other  teeth,  or  results 
Fig.  100  such  as    caries.     The  relation  of  impacted 

^         -k.  teeth  and  any  ulterior  disease  condition  is 

1^      W\        t  -^        settled    by  the    facts,  the   probabilities   of 
fA     Pi       r*  J       relation,  or  the  results  of  their  removal. 
/       T    I     A     /      4  Symptoms. — The  most  common  symptom 

I       j     ^K    J^      attendant  upon  impaction  of  teeth,  judging 
from  the  obtainable  records  of  cases,  is  tri- 

by'"?uSc'ar''opTaW  ^^^^^1  ^^^^^^^^  o(  any  degree,  caused  by 
(Cryer.)  impingement  of   the  malposed  tooth    upon 

nerve  filaments  or  trunks.  Cryer^  records  a 
case  where  a  supramaxillary  neuralgia  was  traced  to  the  presence  of  a 
central  and  lateral  incisor,  and  a  cuspid  tooth  in  the  anterior  wall 
of  the  antrum;  they  were  only  discovered  by  an  exploratory  opera- 
tion.   A  cure  of  the  neuralgia  was  effected  by  their  removal. 

Impacted  third  molars  frequently  give  rise  to  heavy  rheumatic 
pains  about  the  side  of  the  face  and  jaws,  and  no  doubt  in  such  cases 
as  depicted  in  Fig.  85  would  cause  intractable  and  diffuse  maxillary 
neuralgia.  Salter^  records  a  case  of  long  standing  and  intractable 
neuralgia,  exhibiting  a  constant  painful  area  upon  the  scalp,  and  in 
which  heat  and  tenderness  were  noticed  over  a  swelling  upon  the 
hard  palate.  Immediate  and  permanent  cessation  of  the  neuralgia 
followed  removal  of  the  teeth. 

Dr.  N.  T.  Shields^  describes  a  case  of  great  pain  in  the  region  of 
the  mental  foramen,  accompanied  by  a  later  appearance  of  fever, 
reaching  103.8°,  with  subsequent  enlargement  of  the  submaxillary 

'  Jameson:  International  Dental  Journal,  1899. 

2  Boral:  See  Cosmos,  December,  1911. 

3  Dental  Cosmos,  1896. 

*  Dental  Pathology  and  Surgery. 
'Sp.ental  Cosmp_s,  JL.908. 


IMPACTED  AND  ENCYSTED   TEETH 


127 


gland,  as  cured  by  the  surgical  removal  of  the  two  impacted  bicuspids 
and  deciduous  tooth  shown  in  Fig.  101. 

Symptoms  of  maxillary  periostitis — heavy,  gnawing,  and  dull, 
throbbing  pain,  with  more  or  less  heat  and  engorgement  of  tissues — 
are  noted  as  an  accompaniment  of  impacted  teeth.  Such  symptoms 
may  herald  the  appearance  of  the  tip  of  the  tooth  through  its  bony 
covering  and  gum. 

Fig.  101 


Radiograph  showing  impacted  teeth.      (Shields.) 


Cases  of  maxillary  abscess,  in  the  absence  of  their  usual  cause 
(gangrenous  pulp),  may  run  a  prolonged  and  painful  course,^  involv- 
ing neighboring  structures,  which  may  be  vital,  and  after  free  venting 
be  found  to  have  arisen  about  an  impacted  tooth.     The  probable 

1  See  Garretson's  Oral  Surgery  and  Salter's  Dental  Pathology. 


12S 


MALPOSITION  AND  IMPACTION  OF  TEETH 


explanation  for  many  cases  is  the  partial  absorption  of  the  overlying 
tissues,  permitting  ingress  of  bacteria,  but  in  some  cases  crown 
resorption  may  cause  irritation,  and  bacteria  in  the  blood  may 
localize.  A  few  cases  of  pulp  exposure  have  been  seen  when  a  sinus 
allowed  ingress  of  bacteria  and  the  production  of  caries.  In  such 
case  a  pulp  may  die,  undergo  putresence,  and  cause  apical  abscess 
with  its  symptoms. 

In  some  cases  the  pus  travels  from  about  the  impacted  tooth  to 
distant  parts,  as  through  the  musculature  of  the  neck  to  the  clavicle.^ 

Occasionally  a  circumscribed  swelling  is  noted  upon  some  aspect 
of  a  jaw,  most  frequently  upon  the  palatal  portion  of  the  superior 
maxilla,  which  is  attended  by  inflammatory  symptoms,  and  an 
incision  reveals  an  impacted  tooth.  If  a  plate  has  been  worn,  the 
tissue  between,  and  even  the  bone  may  become  necrotic. 


Fig.   102 


Fig.  103 


H"i 


X-ray  photograph,  showing  mal- 
posed  cuspid  entirely  embedded  in  the 
bone  and  pressing  upon  the  central. 


Impacted   cuspid  revealed  by  resorption 
of  the  overlying  tissues.      (Burchard.) 


Quickly  forming  cysts  of  the  jaw,  upon  receiving  surgical  treat- 
ment, may  be  found  to  contain  the  cro"s\Ti  of  an  entire  tooth,  this 
evidently  being  the  centre  of  irritation  from  which  the  cystic  forma- 
tion had  its  origin.  Melancholia,  mania,  and  dementia  precox  have 
been  relieved  by  the  extraction  of  impacted  teeth  diagnosed  by 
radiography.-  This  shows  a  relation  between  cause  and  effect  (Fig. 
106).  M.  C.  Smith^  reports  a  case  of  lifelong  attacks  of  prostrat- 
ing sick  headache  due  to  impaction  of  a  third  lower  molar  and 
relieved  by  its  extraction. 

The  pulps  of  other  teeth  have  been  devitalized  by  the  strangula- 


1  Lyons:     Jour.  Nat.  Dent.  Assn.,  1916,  p.  33.. 

2  Upson:  Dental  Cosmos,  1910,  p.  527. 

3  Dental  Brief,  1912. 


IMPACTED  AND  ENCYSTED  TEETH  129 

tion  due  to  the  pressure  of  the  crown  of  the  impacted  tooth  upon 
the  apical  tissue,  and  the  production  of  pulp  nodules  in  other 
teeth  through  a  reflex  hyperemia  has  been  noted.  The  resorption 
of  roots  of  other  teeth  has  been  produced  by  the  pressure  of  the 
impacted  tooth. 

Hypercementosis  and  concrescence  have  also  been  produced  by 
the  descent  of  the  tooth  and  have  produced  impaction. 

Resorption  of  the  roots  of  the  impacted  teeth,  or  resorption  of  the 
enamel  and  dentin  of  the  crown  may  occur.  In  one  case,  a  calculus 
in  nowise  associated  with  the  oral  cavity,  and  divided  from  it  by  an 
area  of  pericemental  tissue  was  found.  (See  Resorption  of  Enamel, 
for  illustration.) 

In  all  these  cases  diagnostic  features  exist,  though  none  are  com- 
parable to  radiography. 

Diagnosis. — Given  symptoms  not  otherwise  explainable  or  the 
absence  of  a  tooth  from  the  usual  position,  or  both,  an  extraction  or 
impaction  is  suspected,  eliminating  the  first  a  radiograph  is  made. 

A  tumefaction  with  a  tooth  absent  from  the  arch  is  some  evidence. 

Impacted  teeth  may  become  uncovered  at  some  aspect  late  in 
life,  and  the  condition  be  discovered  incidentally.  Cases  are  recorded 
where  the  pressure  of  a  plate  has  caused  the  resorption  of  tissues 
overlying  an  impacted  tooth,  thus  revealing  its  presence.  Fig.  103 
illustrates  a  case  where  the  presence  of  an  impacted  cuspid  was 
revealed  at  the  age  of  seventy  years,  through  resorption  of  the 
alveolar  bone  and  the  gum  tissue  covering  the  tooth. 

Impacted  molars  with  an  opening  leading,  to  them  may  be  detected 
by  instrumental  exploration,  or  a  sharp  bistoury  or  exploring  needle 
may  be  thrust  through  the  gum  and  bone. 

As  the  smooth  feel  of  enamel  is  a  diagnostic  feature  when  instru- 
mental examination  is  made,  it  is  to  be  remembered  that  the  enamel 
and  dentin  of  an  impacted  tooth  may  undergo  a  true  resorption 
with  the  characteristic  Howship's  lacunse.  When  partly  exposed 
to  the  oral  fluid,  caries  may  occur.  Both  these  conditions  produce 
rough  surfaces,  but  enamel  may  usually  be  felt  at  some  point.  In 
all  cases  a  radiograph  is  necessary  to  determine  the  position  of  the 
tooth  and  the  steps  necessary  for  its  removal. 

Plate  exposures  may  be  best  in  obscure  cases  to  determine  a  locality 
for  further  examination  with  a  film  exposure.     (See  Radiography.) 

Treatment.- — The  treatment  of  cases  of  impaction  is  ordinarily  the 
removal  of  the  offending  tooth.  When  the  tooth  is  embedded  deeply 
in  the  substance  of  the  jaw,  access  to  it  involves  conductive  anesthesia, 
and  the  removal  of  the  bone  which  obstructs  the  path  of  extraction; 
this  may  be  an  operation  of  some  magnitude,  and  is  usually  done  by 
9 


130 


MALPOSITION  AND  IMPACTION  OF  TEETH 


a  special  surgical  practitioner.  When,  however,  it  is  evident  that 
the  obstructions  to  the  removal  of  the  tooth  consist  of  the  soft 
tissues  and  but  a  lamina  of  bone,  the  operation  for  removal  is  clearly 
within  the  province  of  the  dental  operator.  For  example,  the  pres- 
ence of  an  impacted  cuspid  is  determined,  lying  horizontally  along 
the  lateral  aspect  of  the  roof  of  the  mouth.     The  parts  may  be 


Fig.   104 


Fig.  105 


Impacted  lower  third  molar;    cause  of 
neuralgia.      (Radiograph  by  Lodge.) 


Cuspid  tooth,  unsuspected  by  patient; 
demonstrated  to  have  been  responsible 
for  severe  neuralgias.  Patient,  a 
draughtsman,  had  not  been  able  to 
work  at  his  business  for  the  six  months 
previous.  The  tooth  was  not  known 
to  be  present,  until  revealed  by  x-rays. 
It  was  removed  from  the  lingual  side. 
(Radiograph  by  Lodge.) 


Fig.  106 


Impaction  of  upper  third  molar,  without  local  pain,  cause  of  profound  delusions  and 
melancholia.    (Upson. 0 

injected  with  a  local  anesthetic  solution,  and  a  cut  made  with  a 
sharp  bistoury  through  the  soft  tissues  from  the  outside  of  the 
swelling,  to  the  bone.  The  flap  thus  outlined  is  raised  from  the 
bone,  the  flap  including  the  periosteum.  A  large,  sharp  bur  is  then 
employed  to  remove  the  covering  bone.    When  the  tooth  is  freely 


Insanity  Caused  by  Painless  Dental  Disease,  Dental  Cosmos,  1910. 


IMPACTED  AND  ENCYSTED  TEETH  131 

exposed  it  may  be  dislodged  with  forceps  or  elevator.  The  parts 
are  then  washed  with  normal  salt  solution,  dried,  the  flap  pressed 
back  into  place,  and  steresoP  painted  over  the  parts,  or  a  stitch  or 
two  of  sterile  horsehair  may  be  taken  before  application  of  the  steresol. 
The  operation  should  be  done  under  aseptic  precaution  and  the 
mouth  should  of  coiu-se  be  kept  as  aseptic  as  possible  before  and 
after  operation.    A  simple  clot  kept  aseptic  may  be  sufficient. 

I^ — Purified  gum  lac gix 

Purified  gum  benzoin 5^ 

Balsam  of  tolu g  j 

Oil  of  cinnamon  (Chinese) §i 

Carbolic  acid giij 

Saccharin §i 

Alcohol Oij — M. 

'  Dental  Cosmos,  1895. 


SECTION  III. 
DEVELOPMENTAL  ABNORMALITIES. 


CHAPTER  V. 
MALFORIVIATIOXS  AND  ANOMALIES  OF  THE  TEETH. 

By  malformation  is  meant  either  a  microscopic  abnormality  in  the 
histology  of  one  or  more  tissues  of  a  tooth  or  a  developmental  error 
which  is  plainly  visible  to  the  naked  eye  and  often  constitute  a  dis- 
tinctly abnormal  tooth  form  or  anomaly.  The  term  anomaly  also 
includes  unusual  peculiarities  such  as  duplication,  absence  of  teeth, 
etc.,  in  which  development  has  to  be  considered.  When  teeth  are 
maKormed  through  some  abnormal  developmental  process  which 
may  be  referred  to  an  abnormal  nutritional  process  the  condition  is 
termed  a  dystrophy,  and  when  this  is  due  to  an  arrested  development 
the  term  hypoplasia  is  properly  employed;  the  term  atrophy  in  this 
connection  is  a  misnomer  as  this  is  a  lessening  in  a  size  previously 
attained  through  a  process  of  normal  nutrition.  The  Unes  cannot 
be  sharply  drawn  as  macroscopic  appearances  may  requu-e  microscopy 
for  their  elucidation. 

For  convenience  the  defects  clearly  microscopic  will  be  classed  as 
such  while  the  more  gross  will  be  classed  as  macroscopic. 

As  malformations  of  the  parts  about  the  mouth  and  of  the  teeth 
are  dependent  upon  defective  development  of  the  same,  it  is  incum- 
bent that  certain  facts  concerning  their  embryology  should  be 
stated.  In  like  manner,  as  the  processes  of  pathology  are  modified 
by  the  peculiar  anatomy  of  the  teeth  and  associated  parts,  it  is 
necessary  that  a  previous  knowledge  of  these  be  acquired  before 
the  special  dental  pathology  can  be  comprehended.  The  embryo- 
logy of  the  mouth  begins  at  a  very  early  period — before  the  twelfth 
day  the  future  mouth  may  be  located  (His,  Fig.  107).  The  mouth 
and  nasal  cavity  are  circumscribed  by  parts  which  are  developed  by 
outgrowths  from  the  head  fold  of  the  fetus.  Those  structures  imme- 
diately concerned  are  the  lateral  tubercles  arising  from  the  frontal 
prominence  (Fig.  108),  which  grow  downward  and  fuse,  forming  the 

(133) 


134     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 


Fio.  lor 


nose,  the  nasal  septum,  the  intermaxillary  bones,  and  anterior  portion 
of  the  upper  lip  (Figs.  109  and  110).  From  the  sides  of  the  head 
fold  at  the  level  of  the  mouth  and  neck  appear  certain  lateral  pro- 
tuberances, or  pharyngeal 
arches.  The  first  pharyngeal 
arches  (Fig.  107,  4)  divide  into 
(1)  the  superior  maxillary  proc- 
esses (Fig.  107,  5)  and  (2)  the 
inferior  maxillary  processes  (Fig. 
107,  4,  shown  just  beneath  the 
oral  cavity  and  united  in  the 
median  line). 

The  superior  maxillary  proc- 
esses develop  the  palate  bones 
and  the  superior  maxillae.  They 
form  the  balance  of  the  upper 
lip.  The  arch  itself  forms  the 
cheek.  Fig  110,  from  a  case  of 
arrested  development,  illustrates 
the  unions  and  parts  naturally 
formed,    but   here    incomplete. 

Face    of    an    embryo    of    twenty-five    to  Y\g.   Ill,  in  which  the  UnioU  of 

twenty-eight  days  (magnified  fifteen  tunes) :  . 

1,  frontal  prominence;    2,  3,  right  and  left  the  proCCSSCS  IS  Still  mCOmplctC, 

olfactory   fossae;     4.    inferior   maxillary    tu-  g^ows  hoW  this  and  cleft  palate 

bercles,  united  in  the  middle  line;  5,  superior  -^ 

maxillary  tubercles;    6,  mouth  or  fauces;    7,  Can  OCCUr. 

second  pharyngeal  arch;   8   third;   9.  fourth;  Secondary   prOCCSSCS    dcVclop 

10,   primitive  ocular  vesicle;     11,   primitive  •/     x-                                     x- 


auditory  vesicle.     (Gray.) 


horizontally  toward  each  other, 


Fig.  108 


Sup.  tubercle 
Lateral  tubercle 


Sup.  tubercle 
Lateral  tubercle 


Head  of  an  early  human  embryo,  showing  the  disposition  of  the  facial  fissures  and 
the  superior  and  lateral  tubercles.     (His.) 


MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH     135 


S.M.P 


S.M.P. 


NAS. 

Diagram  illustrating  scheme  of  union  of  the  processes:  N.S.,  lateral  tubercles 
forming  internal  maxillary  bones,  INT.  MAX.,  and  nasal  septum;  S.M.P.,  superior 
maxillary  processes  forming  palatal  processes  of  superior  maxillae,  S.M.P.;  N.C., 
nasal  cavity;   O.C,  oral  cavity;   I.M.,  inferior  maxillary  processes  united. 


Fig.   110 


Complete  bilateral  fissures  (coloboma)  of  face.     (Guersant.) 


136     MALFORMATIONS  AND  ANOMALIES  OF   THE   TEETH 

form  the  palatal  portions  of  the  superior  maxillse  and  palate  bones,  and 
unite  at  the  median  line  (Fig.  109,  S.M.P.,  also  Fig.  Ill),  forming  the 
vault  of  the  mouth  and  floor  of  the  nasal  cavity.  Union  occurs  with 
the  lateral  processes,  later  forming  the  ^^omer  and  intermaxillary 
bones  and  bearing  the  germs  of  the  incisor  teeth  (Fig.  Ill),  thus  com- 
pleting the  formation  of  the  upper  jaw  and  lip. 

Fig.  Ill 


.^y 


n 


6     \ 


Vertical  transverse  section  through  head  of  human  embryo,  about  the  tenth  week; 
1,  nasal  cartilage;  2,  buccal  cavity;  3,  tongue;  4,  dental  ridge,  lower  jaw;  5,  nasal 
cavity;    6,  dental  ridge,  upper  jaw;    7,  dental  ridge,  lower  jaw.      X  30.     (Broomell.') 


The  inferior  maxillary  processes  grow  forward  and  unite  at  the 
median  line,  developing  the  inferior  jaw  and  lip.  Fig.  115,  an  arrested 
case,  shows  this. 

It  is  to  be  remembered  that  these  processes  are  formed  by  the  out- 
growth of  the  mesoblastic  layer  of  the  blastoderm,  and  are  covered  by 
epithelial  tissue  springing  from  the  epiblast.  Both  are  concerned  in 
the  formation  of  the  teeth.  Epithelium  is  reflected  over  the  face  and 
oral  cavity.  All  tissues  between  these  layers  of  epithelium  excepting 
the  dental  band  and  enamel  organs  and  the  nerves  are  of  mesoblastic 
origin. 

The  structures  of  the  floor  of  the  mouth  and  neighboring  structures 

1  Anatomy  and  Histology  of  the  Mouth  and  Teeth. 


MALFORMATIONS  AND  ANOMALIES  OF  THE   TEETH     137 

are  formed  from  the  second,  third,  and  fourth  pharyngeal  arches  and 
a  tubercle  arising  near  the  first  pharyngeal  arch.  The  fusions  of  the 
lateral  portions  of  the  upper  maxillae  begin  first  anteriorly  at  about 


One  for  nasal  and 
facial  portions. 


One  for  orbital  and 
malar  portions. 


One  for  incisive 
portion. 


One  for  palatal 
portion. 


Fig.   112 


Anterior  Surface. 


At  birth. 


Inferior  Surface. 

Development  of  the  superior  maxillary  bone  by  four  centers,  also  development  of 
intermaxillary  bones.      (Gray.) 


Fig.   113 


Fig.  114 


Cleft  of  hard  and  soft  palate;  rudimen- 
tary intermaxillary  bone  placed  in  advance 
of  lips.     (Mason.) 


Cleft  of  hard  and  soft  palate. 
(Mason.) 


the  eighth  week,  and  progress  posteriorly  until  complete  at  about  the 
eleventh.  Malformations  due  to  non-union,  therefore,  date  from 
this  period,  and  consist  of  the  following  typical  varieties : 


138     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

1.  Non-union  of  lip  on  one  or  both  sides — simple  hare-lip. 

2.  Non-union  of  lip  and  of  maxilla  and  intermaxillary  bone  on  one 
side  (hare-lip,  Fig.  113). 

3.  Non-union  of  lip  and  intermaxillary  bone  on  both  sides  (double 
hare-lip,  when  complete  bilateral  fissures  are  formed  it  is  termed 
Coloboma,  Figs.  Ill,  113,  114,  117). 

4.  Non-union  of  all  horizontal  processes  in  the  median  line  (cleft 
palate,  Figs.  113  and  114).  (It  may  be  double,  divided  by  the  vomer, 
including  the  hard  palate.^) 

5.  Non-union  of  halves  of  soft  palate  (cleft  velum).  (Usually 
involving  part  of  the  hard  palate.) 

Fig.   115 


Median  fissure  of  the  lower  lip  and  chin.     (Marshall,  after  Wofler.) 

6.  Non-union  of  halves  of  the  uvula  (bifid  or  cleft  uvula). 

Combinations  of  cleft  velum  and  cleft  palate  or  of  cleft  palate  and 
single  or  double  hare-lip  may  exist. 

A  case  of  failure  of  development  of  the  intermaxillary  bones  has 
been  reported,^  the  space  between  the  cuspid  teeth  being  about 
one-eighth  inch. 

Figs.  110  to  114  show  the  parts  in  their  ununited  state. 

The  failure  of  the  inferior  maxillary  processes  to  unite  is  rare, 


'  Brown:  Oral  Diseases  and  Malformations. 
2  Jeffery,  British  Dental  Journal,  July,  1904. 


MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH     139 

but  is  occasionally  seen  (Fig.  115).    There  is  some  evidence  of  heredi- 
tary   influence  in    many  cases. ^     The  inferior  maxillary  tubercles 


Fig.   116 


Fig.   117 


M.a 


Showing  Meckel's  cartilage   (M.C.)   in  Osteology  of  hare-lip.     (Museum  of  the 

longitudinal  and  transverse  section.  Philadelphia  Dental  College.) 

Fig.   118 


Section  of  jaw,  embryo  of  pig,  sho'W'ing  growth  of  enamel  organ  and  dentin  germ: 
1,  enamel. organ;  2,  dentin  germ;  3,  growth  of  jaw;  4,  tongue.      (Andrews.) 

1  Brown:  Oral  Diseases  and  Malformations.     Hiunphreys:  Dental  Cosmos,  1914, 
p.  44.     Blades:  Dental  Cosmos,  November,  1914. 


140     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

develop  a  transitory  support  to  the  lower  jaw  known  as  Meckel's 
cartilage.  The  cartilages  of  the  right  and  left  side  do  not  fuse 
together  at  the  future  symphysis.  (Hertwig.)  (Figs.  Ill  and  116.) 
It  acts  as  a  support  to  the  fetal  jaw,  undergoes  atrophy  at  about 
the  sixth  month  of  gestation,  and  at  birth  but  few  fragments  are 
found  near  the  symphysis.    At  birth  ossification  has  occurred,  and 


Fig.  119 


K"< 


Section  of  developing  tooth  of  an  oiuLiryo  calf:  a,  stellate  reticulum  of  enamel 
organ;  b,  stratum  intermedium;  c,  ameloblasts;  d,  dentin;  e,  odontoblasts;  /,  blood- 
vessels— corpuscles  in  situ.     X  275.     (Williams.) 

the  bone  consists  of  two  halves  united  by  a  fibrous  symphysis  in 
which  ossification  takes  place  during  the  first  year. 

The  end  of  the  cartilage  in  the  base  of  the  inferior  maxillary  process 
becomes  the  future  malleus  (one  of  the  bones  of  the  middle  ear).  The 
portion  of  the  cartilage  running  from  the  malleus  to  the  formed  bony 
lower  jaw  becomes  transformed  into  the  internal  lateral  ligament  of 
the  inferior  maxilla.    (Hertwig.) 


MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH     141 

We  must  keep  in  mind  the  foregoing  facts  and  also  the  process  of 
tooth  development  by  the  three  formative  organs. 

1.  The  enamel  organ  lined  upon  its  under  siu-face  with  amelo- 
blasts  (Figs.  US  and  119),  which  deposit  enamel  as  enamel  globules 
cemented  together  by  inter 'prismatic  cement  substance,  the  tw^o  forming 
finally  an  enamel  rod  or  prism.  The  rods  are  cemented  together  by 
the  interprismatic  cement  substance  (Fig.  121). 

Fig.  120 


Mode  of  enamel  deposition:  A,  formed  enamel;  B,  ameloblasts;  C,  secreting 
papillae  of  stratum  intermedium;  D,  bloodvessels  in  external  fibrous  coat  and  to 
secreting  papillae;  E,  enamel  globules  with  connecting  plasmic  strings;  F,  nuclei 
of  ameloblasts;  G,  blood  supply  of  odontoblastic  layer;  H,  odontoblasts;  I,  un- 
formed dentin;  /,  formed  dentin.  The  interprismatic  cement  substance  is  shown  as 
smaller  bodies  within  the  ameloblasts.     Semidiagrammatic.     (Wihiams.) 


2.  The  dentmal  papilla  (the  dentin  organ)  covered  upon  its  outer 
surface  by  odontoblasts  (Figs.  118  and  119)  which  deposit  dentin 
globules  cemented  together  by  dentinal  ceinent  substance,  both  exuded 
by  odontoblasts  (Mummery).  The  odontoblasts  leave  portions  of 
themselves  within  the  dentinal  tubules  constructed  by  themselves, 
these  tubes  lying  within  a  general  dentinal  substance  known  as 


142     MALFORMATIONS  AND  ANOMALIES  OF   THE  TEETH 

intertuhiilar  substance.     The  result  of  this  mode  of  development  of 
dentin  is  nicely  shown  in  Figs.  122  and  123. 


Fig.   121 


Section  of  enamel  of  human  tootli.  Photogiaplied  with  Zeiss  apochromatic  lens 
and  Powel  and  Leland  apochromatic  condenser.  The  optical  parts  accurately  centred 
and  the  focus  "critical."  The  enamel  rods  are  seen  to  be  resolved  into  distinct  sec- 
tions (enamel  globules),  the  cement  substance  often  passing  entirely  between  the 
sections.      X  400.     (Williams.) 

Fig.  122 


Transverse  ground  section  through  the  dentinal  tubules  of  the  first  molar  of  a  child, 
aged  seven  years:  V,  small  connecting  tubule.  Koch's  and  Golgi's  methods  combined 
X  1200.     (Rose.) 


MICROSCOPIC  MALFORMATIONS 


143 


3.  The  follicle  wall  (the  cement  organ)  and  later  the  pericementum, 
a  fibrovasciilar  membrane  containing  on  its  inner  and  outer  surfaces 
osteoblasts  which  form  respectively  the  cementum  of  the  root  as  a 
modified  bone  and  the  alveolar  wall.  It  completely  encircles  the 
enamel  organ  and  papilla  and  any  of  their  products  and  with  its 
enclosures  constitutes  the  dental  JoUicle.  It  is  upon  aberrations  in 
these  three  organs  that  dystrophies  and  anomalies  of  teeth  depend. 

Fig.   123 


Main  mass  of  dentin  of  a  temporary  tooth,  stained  with  chlorid  of  gold,  decalcified 
with  acetic  acid:  F,  F,  dentinal  fibers,  partly  vacuolated;  B,  B,  basic  substance, 
traversed  by  a  reticulum.     X  1200.     (Hart.) 


MICROSCOPIC   MALFORMATIONS. 

Microscopic  or  histological  defects  may  affect  any  of  the  dental 
tissues,  enamel,  dentin,  cementum,  pulp,  or  pericementum. 

Enamel. — Defects  in  enamel  structures  range  from  any  degree  of 
orderliness  in  the  even  distribution  of  globular  bodies  and  cementing 
substance  in  the  tissue,  to  gross  aberrations  in  formation.  The  finer 
variations  of  structure  are  not  easily  recognizable. 

Theoretically  perfect  enamel  should  show  in  longitudinal  section  a 
series  of  squares  of  uniform  size  built  into  rods,  the  outlines  of 
the  squares  and  rods  being  marked  by  lines  of  cementing  substance 
having  a  refractive  index  slightly  different  from  that  of  the  squares 


144     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

(Fig.  121).  While  such  a  structure  is  perhaps  never  found,  it  is 
difficult  to  draw  a  line  where  aberrations  from  such  a  standard  become 
pathological.  An  arbitrary  standard  might  be  assumed  as  follows: 
Regard  any  enamel  as  pathological,  where  areas  of  it  differ  from  its 
general  substance  to  such  an  extent  as  to  have  a  decidedly  different 
refractive  index.  A  typical  form  of  abnormality  is  noted  in  what 
are  kno^Ti  as  opaque  spots  in  the  enamel,  areas  in  which  an  opaque 
surface  exists  instead  of  the  normally  translucent  enamel. 

Fig.  124 


')i-i' 

Mpi 

^^f /^ ", 

j^^^^^^iU^'-^'^- 

■                 \   ■.       :■     >, 

Section  of  human  molar,  showing  dentinal  fibrillce  penetrating  enamel.     X  600. 

(WiUiams.i) 


Dentinal  Fibrils  in  Enamel. — The  dentinal  fibrillse  may  penetrate 
the  substance  of  the  enamel  (Fig.  124),  occupying  defined  channels 

^  For  an  interesting  article  illustrating  this  point  see  Boedecker,  Dental  Cosmos, 
1911,  p.  1000, 


MICROSCOPIC  MALFORMATIONS 


145 


in  its  substance;  this  was  formerly  regarded  as  a  developmental 
accident.  Caush^  claims  to  have  found  this  to  be  a  normal  condi- 
tion of  human  enamel,  and  regards  these  as  nutrient  spaces.  Still 
later  Boedecker  has  found  them  to  frequently  occur  in  enamel  (Fig. 
126).  Andrews^  states  that  ''examination  of  sections  at  the  junc- 
tion of  formed  dentin  and  ameloblasts  show  fibers  span  any  space 
formed  between  them."  Evidently  there  must  have  occurred  a 
mixture  of  the  elements  of  dentin  and  enamel,  the  record  showing  an 

Fig.  125 


Section  of  human  incisor,  showing  "bands  of  Retzius"  and  marked  stratification  of 
enamel.     X  125.     (WilUams.) 

interdigitation  of  papilla  (probably  odontoblasts)  and  enamel  organ 
(probably  ameloblasts) .  After  calcification  these  odontoblastic  fibers 
are  caught  in  the  enamel.  Von  Beust  also  has  experimentally  shown 
this  (Fig.  126).  Gies^  injected  trypan  blue  into  the  peritoneal  cavity 
of  animals  and  found  it  in  the  pulp,  dentin  and  to  an  extent  in  the 
enamel.  Such  conditions  are  not  to  be  confounded  with  fissures  of 
enamel  where  large  lines  of  faulty  calcification  or  non-calcification 


1  International  Dental  Journal,  June,  1904. 

2  Dental  Cosmos.  1912,  p.  49. 

'  Journal  of  Allied  Dental  Societies,  September,  1914. 


10 


14G      MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

Fig.  126 


Injected  tooth,  showing  connection  between  dentinal  tubules  and  enamel  tubes. 

(von  Beust.) 


Fig    127 


Specimen  of  decalcified  adult  enamel,  showing  enamel  prism  sheaths  and  lamella  (L), 
cut  longitudinally.     X  500.    (Boedecker.)  ^ 


MICROSCOPIC  MALFORMATIONS 


147 


extend  through  the  thickness  of  enamel.  A  portion  of  the  enamel 
may  occupy  an  area  within  the  dentin.  This  in  itself  shows  that  the 
enamel  and  dentin  organs  can  be  heterogeneously  arranged.  An 
odontoma  is  another  evidence. 

Enamel,  even  normal  enamel,  is  not  of  uniform  composition;  were 
it  so,  it  would  exhibit,  in  addition  to  an  orderly  arrangement  of  its 
histological  elements,  a  uniformity  in  color.  So  common  are  differ- 
ences in  this  direction  that  the  presence  of  pigment  bands  must  be 
regarded  as  normal.  It  is  the  rule  to  find  enamel  traversed  by  deeply 
pigmented  parallel  bands,  which  pass  obliquely  upward  from  the 
surface  of  the  dentin  to  the  surface  of  the  enamel.  These  are  termed 
the  bands  of  Retzius;  they  appear  to  mark  the  size  of  the  enamel 
cap  at  successive  periods  of  its  growth  (Fig.  125). 

Fig.  128 


Injected   tooth,  showing  connection  between  dentinal    tubules  and  lacunae  of 
cementum.     (von  Beust.) 


Stratification  and  striation  of  the  enamel,  as  shown  by  Williams, 
must  be  regarded  as  normal  physiological  records  of  the  mode  of 
enamel  formation.  Kirk  has  shown  that  normal  enamel  shows  vari- 
ations in  density  in  the  same  teeth. 

All  of  these  histological  defects  represent  variations  of  deposition, 
no  doubt  due  to  fluctuation  of  the  nutritive  processes  of  the  child  at 
the  time  of  tooth  formation.  Histological  records  made  in  the  enamel 
are  not  like  those  made  in  other  tissues,  for  there  is  no  certain  pro- 
vision through  which  such  defects  can  be  remedied  at  subsequent 
periods. 


148     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

Profound  nutritive  disturbances,  such  as  those  attending  hereditary 
s}i)hilis  in  children,  affect  the  structures  of  the  teeth.  One  of  the 
gross  results  of  this  disease  is  a  common  malformation  of  the  general 
form  of  the  incisors.  The  hard  tissues  of  such  teeth  exhibit  micro- 
scopic evidences  of  faulty  histology;  they  are  dull  and  opaque,  and 
traversed  by  irregular  bands.  Viewed  in  section,  the  enamel  of  such 
teeth  is  seen  to  be  almost  structureless  (Fig.  129).  Williams  found 
that  the  contents  of  the  large,  irregular  spaces  in  this  enamel  did  not 
respond  to  stains — i.  e.,  did  not  contain  organic  matter.  Such  teeth, 
when  not  presenting  gross  malformations,  may  have  a  distinct  irregu- 
larity of  enamel  surface.  This  may  even  be  seen  with  the  naked  eye, 
or  graphite  may  be  rubbed  over  the  teeth,  bringing  out  the  lines. 

Fig.  129 


Section  of  enamel  from  syphilitic  tooth,  with  appearances  resembling  the  lacuna;  of 
cementum.     X  600.    (Williams.) 

Among  the  poor  children  in  clinical  service  opacity  of  enamel  is 
frequently  noted,  whether  this  is  due  to  syphilis  or  to  general  nutritive 
disturbances  was  not  investigated,  but  in  view  of  the  available 
evidence  it  would  seem  most  just  to  attribute  it  to  abnormal  nutri- 
tion.i  As  a  prophylactic  measure  breast  feeding  of  the  child  and  ample 
nutrition  of  the  parent  and  child  seems  the  indication  if  applicable. 

Stripes  of  Schreger. — Cloud-like  markings  are  also  seen  in  enamel, 
which  are  called  the  stripes  of  Schreger.     They  run  from  dentin 

1  See  Structure  as  Predisposing  Cause  of  Dental  Caries. 


MICROSCOPIC  MALFORMATIONS 


149 


toward  the  periphery,  and  are  considered  by  Pickerill  to  be  due  to  an 
optical  effect  produced  by  superimposed  prisms^  (Fig.  130). 

Lodge,^  in  an  investigation  of  this  subject,  found  that  if  a  section 
of  enamel  was  made  at  an  angle  of  45  degrees  to  the  axis  of  the  prisms 
the  optical  effect  recognized  as  Schreger's  bands  and  which  ordinarily 
are  seen  only  at  the  dentinal  two-thirds  can  then  be  seen  running 
entirely  to  the  periphery.  He  further  states  that  the  structure  of 
teeth  susceptible  to  caries  renders  the  refractive  indices  of  the  prisms 
unequal  and  therefore  more  likely  to  produce  the  cloud  effect.    He 

Fig.  130 


Enamel  and  dentin,  human  tooth:  1,  enamel;  2,  dentin;  1,  lines  of  Schreger  in 
enamel;  4,  brown  striae  of  Retzius.  (Probably  aggregation  of  tubes,  editor.)  (Broomell, 
after  Geise.) 

deduces  that  enamel  of  perfect  quality  would  account  by  its  equal 
light  refraction  of  the  prisms  for  specimens  cut  at  45  degrees  to  axis 
and  lacking  the  stripes  of  Schreger. 

"  With  reflected  light  only  the  lines  appear  of  a  bluish  or  slaty  color, 
the  intervening  areas  white — with  a  small  admixture  of  substage 
light  the  dark  bands  are  areas  of  considerable  translucency  and  the 
intervening  areas  opaque  white."  He  is  therefore  in  accord  with 
those  who  agree  upon  an  optical  effect  as  the  cause  of  these  phe- 


1  Pickerill,  Dental  Cosmos,  October,  1913. 

2  Dental  Cosmos,  November,  1917. 


150     MALFORMATIONS  AMD  ANOMALIES  OF  THE  TEETH 

nomena,   and  as  they  are  in  effect  superimposition  of  a  net-like 
structure,  he  proposes  the  rational  term  "reticulum  lines." 

There  is  evidence  that  other  forms  of  specific  dermatitis — scarlet 
fever  and  measles — which  occur  at  an  early  age  may  affect  the 
formation  of  enamel.  The  gross  defects  attributed  to  the  exan- 
themata are  irregular  pits  upon  the  crowns  of,  particularly,  the 
incisors  (Fig.  141,  etc.),  though  other  teeth  also  suffer.  In  some 
cases  the  crowns  appear  honeycombed.  The  condition  is  known  as 
hypoplasia  of  the  enamel,  and  is  evidently  due  to  an  effect  upon  the 
enamel  organs.  The  microscopic  structure  is  also  affected.  There 
is  evidence  in  some  specimens  (Fig.  148)  that  the  dentin  may 
be  hypoplastic;  the  papilla  being  doubtless  affected  by  the    pre- 

FiG.   131 


Lines  of  Schreger  in  the  enamel  of  a  permanent  and  deciduous  tooth  (human). 
Bulge  of  enamel  at  cervix  of  deciduous  tooth  is  shown  due  to  bulging  of  dentin,  not 
to  thickness  of  enamel.     (Pickerill.) 

vailing  systemic  malnutrition.  The  dentin  being  first  developed, 
shows  perhaps  normal  for  a  distance,  then  a  row  of  interglobular 
spaces  is  found,  which  is  evidence  that  the  dentin  organ  is  affected 
by  the  general  disturbance  at  the  same  time  as  the  enamel  organ. 

Hopewell-Smith^  describes  the  enamel  developed  during  rickets  as 
faulty,  and,  in  so  far  as  limited  observation  could  determine,  con- 
tained numerous  spaces  probably  filled  with  soft  tissue.  These 
spaces  were  in  the  first-formed  portions  of  the  specimens  observed. 

Dentin. — Data  regarding  the  finer  phases  of  defective  histological 
structure  of  the  dentin  are  meagre.    It  has  been  observed  that  the 

1  Loc .  cit. 


MICROSCOPIC  MALFORMATIONS 


151 


dentinal  tubiili  of  some  teeth  are  much  larger  than  in  others  of  the 
same  age,  and,  no  doubt,  future  investigations  with  an  improved 
technique  directed  toward  a  study  of  the  exact  mode  of  dentin 
formation  will  exhibit  defects  more  certainly. 

The  chief  histological  defects  noted  in  dentin  are  areas  of  faulty 
or  non-calcification,  called  interglobular  spaces  (Fig.  132).  These 
are  most  common  in  the  dentin  immediately  underlying  its  covering 
tissue;  so  common  in  the  dentin  under  the  cementum  that  this 
portion  of  dentin  has  been  called  the  stratum  granulosum,  the 
granular  layer  of  Tomes  (Fig.  134).  In  the  body  of  the  dentin  these 
spaces  have  a  more  irregular  distribution. 

Fig.  132 


Section  showing  interglobular  spaces  in  dentin  of  a  syphilitic  human  tooth.     (Williams.) 


In  wet-ground  sections  (Rose)  the  dentinal  filaments  are  seen  to 
pursue  an  unbroken  course  through  these  areas.  The  contents  of  the 
interglobular  spaces  react  to  stains  like  the  sheaths  of  Neumann; 
that  is,  they  probably  contain  transitional  tissue.  These  areas 
probably  represent,  as  do  defective  spots  of  enamel,  periods  of 
depressed  vitality,  or  of  altered  nutrition.  In  the  light  of  present 
know^ledge  regarding  the  subject,  they  are  to  be  viewed  as  areas  in 
which  calcification  was  faulty. 

Interglobular  spaces  afford  some  evidence  of  the  formation  of 
dentin  by  a  deposition  of  globular  bodies  in  a  matrix  of  protoplasmic 


152     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

Fig.  133 


f 


Interglobular  spaces  crossed  by  dentinal  tubes.    Prepared  by  Weil's  process.    Magnified 
240  times.    (Hopewell-Smith.) 


Fig.  134 


-^^'-■\'^K^ 


I) 


Ground  section  through  the  root  of  a  human  premolar:  D,  dentin;  K,  cement 
corpuscles;  0,  osteoblasts;  Ep,  remains  of  Hertwig's  epithelial  root  sheath  or  peri- 
cemental glands  of  Black  :3   J,  interglobular  spaces.     X  200.     (Rose.) 


MICROSCOPIC  MALFORMATIONS 

Fig.  135 


153 


Schreger's  lines  in  dentin.     From  the  ivory  of  the  tusk  of  a  walrus.     Prepared  by 
grinding.     Unstained.      X  45.       (Hopcwell-Smith.) 


Fig.  136 


The  same  as  Fig.  135.      X  420.     (Hopewell-Smith.) 


154     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

material.  The  continuation  of  the  tubules  through  the  mass  of 
uncalcified  contents  is  evidence  of  their  probable  independent  for- 
mation by  special  fibril  cells  as  claimed  by  Andrews. 

Occasionally  lines  appear  in  dentin  at  a  common  developmental 
level  and  having  a  degree  of  parallelism  to  the  pulp  surface.  They 
are  evidently  records  of  a  new  period  of  increment  and  consist  of 
short  curves  in  the  tubules.  They  are  called  contour  lines  of  Owen, 
also  lines  of  Schreger  in  dentin  (Figs.  135  and  136). 

Histological  malformations  of  the  pulp  have  not  been  recorded,  the 
normal  histology  of  the  organ  not  being  made  out  with  sufficient 
certainty  to  determine  what  appearances  are  to  be  regarded  as 
abnormal.     Aberrations  in  form  of  pulp  cavities  are  constant. 

Fig.  137 


'.yyy 


"^ms^Ms^. 


Section  of  a  bicuspid  wath  its  alveolus,  showing  a  pit-like  absorption  upon  the  side 
of  the  root  in  which  the  redeposit  of  the  cementum  has  begun:  a,  dentin;  b,  cementuni; 
c,  peridental  membrane;  d,  bone  forming  the  wall  of  the  alveolus;  e,  absorbed  area  of 
cementum.  It  will  be  noticed  that  a  new  deposit  of  cementum  has  begun  the  filling 
of  the  area,  and  that  the  soft  tissue  in  the  area  of  absorption  is  of  a  cellular  type.  The 
bone  also  shows  the  effects  of  absorption  in  the  cutting  away  of  portions  of  the  ring 
of  the  Haversian  systems  at  /,  while  at  g  the  presence  of  osteoclasts  shows  that  absorp- 
tion is  in  progress  at  that  point.     (Black.) 

Cementum. — The  pericementum  may  contain  numbers  of  mul- 
tinucleated cells — odontoclasts;  and  their  presence  is  not  to 
be  regarded  as  abnormal.  The  cementum  of  the  roots  of  teeth 
may  exhibit  evidences  of  former  action  of  these  cells  in  excava- 
tions of  cementum,  which,  by  a  subsequent  deposition  of  cemen- 
tum, have  become  filled.  This  gives  an  irregular  course  to  the 
cement  laminae  (Fig.  137).  These  appearances  are  to  be  regarded 
as  not  necessarily  pathological,  for  the  following  reason:  for  some 
time  (years)  subsequent  to  the  eruption  of  the  teeth,  developmental 
changes   occur  in  the   alveolar  bones;   depositions   (subperiosteal) 


MACROSCOPIC  MALFORMATIONS  155 

increasing  their  volume  are  accompanied  by  resorption  of  other 
portions  of  the  bone,  such  a  balance  being  kept  between  their  proc- 
esses that  the  teeth,  although  shifting  their  positions,  are  kept  in 
normal  occlusion. 

The  cementum  may  be  thickened  by  additional  deposits,  as  in 
hypercementosis,  which  is  an  excess  of  development  classed  as 
pathological. 

MACROSCOPIC  MALFORMATIONS. 

Under  this  heading  two  subdivisions  will  be  made: 

1.  Dystrophies  of  the  teeth. 

2.  Anomalies  of  development  not  of  dystrophic  character. 
Dystrophies  of  the  Teeth. — There  are  several  forms  of  macroscopic 

malformation  which  seein  due  to  distiu'bances  of  function  or  nutrition 
of  the  developmental  organs  and  this  in  turn  apparently  caused  by 
some  severe  general  disturbance  notably  the  exanthemata  classing 
s;s'philis  with  these. 

Opaque  Spots  in  Enamel.— White,  brown,  and  corn-colored  opaque 
areas  of  enamel  are  frequently  seen,  surrounded  by  apparently  normal 
enamel. 

Examined  without  the  aid  of  the  microscope  they  are  seen  to 
present  a  surface  as  smooth  as  any  enamel,  though  sometimes  slightly 
crenated,  but  upon  this  surface  being  broken  up  with  a  bur  a  chalky, 
granular,  whitish  material  containing  at  times  the  yellowish  pigment 
is  seen,  sometimes  occupying  the  entire  thickness  of  the  enamel. 
These  spots,  if  slight,  are  sometimes  without  this  granular  character, 
while  the  pigment  affects  the  entire  thickness  of  the  affected  enamel. 

Williams  submitted  the  enamel  at  the  borders  of  such  spots  to 
microscopic  examination,  and  compared  it  with  enamel  in  the  first 
stages  of  decay,  finding  in  both  a  similar  appearance,  characteristic 
of  a  lack  of,  or  a  loss  of  interprismatic  cement  substance  (Fig.  138). 

Mottled  Enamel. — H.  A,  Flynn^  called  attention  to  the  prevalence 
of  opaque  enamel  in  87  per  cent,  of  children  born  and  raised  in 
Colorado  Springs  while  only  sparingly  found  in  other  nearby  localities. 

This  condition  has  been  shown  to  exist  in  various  localities  in  about 
this  percentage  and  confined  to  them.  It  is  therefore  an  endemic 
condition.  Black  and  McKay^  in  an  exhaustive  investigation  of  this 
condition  published  the  following  conclusions: 

1.  The  mottled  teeth  are  found  only  in  the  groups  of  permanent 
teeth  subjected  to  the  influence  of  the  local  conditions  while  the 
enamel  is  developing  and  the  temporary  teeth  are  not  affected. 

1  Items  of  Interest,  1910. 

2  Dental  Cosmos,  February  to  August,  1916,  and  Journal  of  Nat.  Dent.  Assn., 
July,  1918  and  April,  1919. 


156     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

2.  The  lingual  siu'faces  are  opaque,  paper  white,  mottled,  with  nor- 
mal spots  and  clouded  areas.  The  labials  are  opaque,  paper  white, 
mottled  with  brown  spots  or  brown  or  black  bands.  The  surface 
glaze  was  present. 

3.  The  general  form  of  the  teeth  was  normal,  though  in  a  few 
cases  hyperplasias  were  also  present  probably  having  no  causal 
relations  (McKay) . 

Fig.  138 


«•  ....     m 

''*l#^ 

m  "•  ^ 

^^I^H 

%^ 

^s 

■  ■-«» 

1  ^ 

■4tt5F 

'  "  "    mm^- .... 

'm. 

■  y 

^«N« 

*    t   ,;        ^. 

t0 

T 

■  ii'-. 

■■-'-       s^-  ^.  ■:^4:^ 

r  n 

^            ■  * 

0M: 

• 

1  41     ■■'*'!*-■*      "**■- 

■  te- 

•W 

# 

T  - 

'Si^. 

♦  ^^ 

*  * 

•#.* 

Portion  of  a  white  spot  in  enamel,  showing  lack  of  interprismatic  cement  substance. 

X  2000.     (Williams.) 


4.  The  enamel  rods  were  well  formed  but  the  interprismatic  cement 
substance  was  replaced  by  a  brown  coloring  pigment  in  the  dark 
colored  areas  (called  hrownin  by  Black),  but  no  cement  substance 
was  found  in  the  opaque  white  areas.  Only  the  superficial  layers  of 
enamel  were  affected.  The  yellow  shades  were  due  to  brownin 
within  the  substance  of  the  enamel  and  showing  through  more 
translucent  enamel  above  it.  The  brownin  appears  in  about  40  per 
cent,  of  the  mottled  cases. 

5.  The  brownin  can  be  dissolved  out  by  immersmg  in  absolute 


MACROSCOPIC  MALFORMATIONS 


157 


alcohol  (four  days)  followed  by  immersion  in  gasoline  (one  month) 
and  the  resulting  opaque  white  tooth  can  be  permeated  with  stains. 

6.  The  condition  is  endemic  to  certain  localities  but  may  appear 
in  children  taken  to  such  localities  in  the  period  of  life  during  which 
the  permanent  teeth  are  developing.  It  is  occasionally  exceptionally 
found  in  other  localities  and  it  may  exist  on  a  few  teeth  only. 

7.  The  teeth  erupt  in  the  mottled  state  but  the  coloring  makes  its 
appearance  some  time  later.  It  is  not  certain  whether  this  pigment 
is  laid  in  before  eruption  or  is  an  infiltration  of  some  exterior  sub- 
stance.^    The  lower  incisors  while  mottled  are  rarely  stained. 

Fig.  139 


Mottled  enamel.     (McKay,  Dental  Cosmos.) 


8.  All  factors  except  residence  in  the  endemic  region  during  enamel 
formation  may  be  excluded.  Removal  from  the  endemic  district 
after  damage  does  not  remove  the  discolorations  while  removal  for  a 
part  of  each  year  during  enamel  formation  seems  to  exercise  an 
inhibitive  influence  upon  the  lesion. 

9.  Exhaustive  analyses  of  the  drinking  water  showed  no  constant 
relation  between  the  lime  or  other  content  and  the  prevalence  of  the 
lesion  nor  could  artificial  feeding  in  infancy  be  related  with  it.  There- 
fore the  cause  remains  obscure  though  later  investigations  seem  to 
show  that  artesian  water  is  probably  most  often  the  source  of  the 
drinking  water,  as  in  several  endemic  districts,  native  children 
raised  on  such  water  had  mottled  teeth,  while  native  children  using 
dug  well  (surface)  water  were  free  from  the  affection. 

1  McKay,  Jour,  Nat.  Dent,  Assn,,  1917,  p.  274. 


158     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

It  is  remarkable  that  the  first  formed  enamel  is  normal  while 
that  later  formed  is  abnormal  yet  the  water  drinking  is  constant. 
The  difference  between  this  condition  and  rickets  which  affects  the 
early  formed  enamel  is  also  notable  (see  Fig.  139). 

McKay,  arguing  against  syphilis  as  a  cause,  points  out  that 
nearby  localities  may  be  afflicted  or  not,  which  syphilis  would  not 
accomplish.  The  treatment  of  mottled  enamel  consists  in  the 
removal  by  grinding  of  the  outer  layer  of  enamel  with  subsequent 
polishing. 

Fig.  140 


Section  through  human  cuspid,  showing  sulcus  and  appearance  of  tissue  in  its  vicinity 
X  75.     (Specimen  by  Choquet;  photograph  by  Williams.) 


In  one  case  of  an  adult  lady,  a  broad,  brown  spot  was  seen  on 
a  lower  left  lateral.  There  was  a  history  of  the  temporary  lateral 
having  been  knocked  out.  The  writer  has  a  Philadelphia  patient 
who  has  the  labials  of  the  upper  incisors  each  marked  with  a  broad 
white  spot  in  the  center  of  which  is  a  large  brown.  No  history  as  to 
the  water  drunk  is  obtainable.  While  the  endemic  regions  show  the 
condition  prevalent,  it  is  not  clear  that  the  defect  is  distinct  from 
the  opaque  spots  mentioned  on  page  155  except  as  to  cause. 

Hypoplasia  of  the  Dental  Structures. — By  hypoplasia  in  this 
connection  is  meant  an  arrested  development  of  any  portion  of  a 
Jooth.     Necessarily  the  tpotb  is  deformed. 


MACROSCOPIC  MALFORMATIONS 


159 


The  term  atrophy  has  been  used  in  this  sense,  but  is  better 
confined  to  a  lessening  in  size  after  normal  development  of  a  part  has 
occurred.  Nutritional  disturbances,  the  exanthemata,  and  S}^hilis 
all  seem  to  have  a  profound  influence  upon  the  form  of  teeth  develop- 
ing during  the  period  of  active  disease,  by  affecting  the  cells  of 
the  formative  organs.  With  the  passing  of  this  period,  the  develop- 
ment of  the  tooth  may  proceed  in  an  orderly  manner.  The  fol- 
lowing forms  of  hypoplasia  are  known : 


Fig.  141 


Fig.  142 


Hypoplasia  due  to  eruptive  fevers. 


Agenesis  of  incisal  portion  of  enamel. 


Pitted  and  Grooved  Teeth. — The  hypoplasias  described  under  this 
heading  may  consist  of  a  series  of  irregular  grooves  or  pittings,  the 
crowns  having  approximately  the  normal  outlines.  Of  these  malfor- 
mations Figs.  141  to  146  are  fairly  typical. 


Fig.  143 


Fig.  144 


Showing  the  front  teeth  grooved  from  the  alternation  of  perfectly  and   imperfectly 
developed  portions  of  enamel.    Hypoplasia.     (Tomes.) 


Black  regards  the  formation  of  pits,  the  simultaneously  developed 
zone  of  enamel  being  perfect,  as  due  to  aberration  in  development  of 
enamel  rods,  leaving  a  hole  (doubtless  a  localized  effect  upon  the 
ameloblasts) .  Histologically  the  strata  of  the  enamel  partly  fail  of 
deposition  at  these  points  (Fig.  141).  The  malformation  follows 
the  striae  of  Retzius. 

With  a  history  of  a  case,  including  the  age  of  the  child  at  the  period 
of  the  disease,  if  examination  be  made  of  the  positions  of  the  defects, 
the  age  will  serve  as  an  indication  as  to  whether  there  has  been  any 


160     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

connection  between  the  eruptive  fever  and  the  dental  malformation. 
For  example,  if  enamel  pits  upon  incisors  have  been  caused  by  an 
eruptive  fever  between  the  ages  of  four  and  five,  they  should  occupy 
a  part  a  little  above  the  half-way  area  of  the  crown  face  of  a  central 
incisor.  The  lateral  will  be  affected  nearer  the  incisal  edge  and  the 
cuspid  still  more  so;  it  is  evident  that  the  enamel  being  already 
formed  about  the  incisal  edge  of  the  tooth,  alterations  of  nutrition 
could  not  affect  the  already  formed  tissue.  (See  Fig.  50.)  The 
enamel  formed  after  a  period  of  attack  may  be  perfect  (Fig.  145). 

Hutchinson's  Teeth  (Hypoplasia). — During  the  first  few  weeks 
after  birth,  skin  eruptions  characteristic  of  hereditary  syphilis  are 
apt  to  occur  in  the  contaminated  child.  At  this  period  the  tips  of 
the  permanent  incisors  are  undergoing  development,  the  first  per- 
manent molar  having  started  at  the  twenty-fifth  week  of  gestation 
(see  Fig.  50),  and  the  effect  of  the  syphilitic  eruption,  during  which 

Fig.  145 


Malformations   of   incisal   half  of   crowns,   with   cervical   half   perfect. 
(Model  by  W.  A.  Capon.) 


Hypoplasia. 


the  protozoon  treponema  pallidum  may  be  in  the  enamel  organ  (or 
there  is  a  severe  disturbance  of  metabolism  brought  about  by  the 
infection,  according  to  the  preferred  view  of  Stein^),  is  to  cause 
a  disturbance  of  the  enamel  organ  and  papilla,  which  produces  a 
defective  development  at  this  point.  Instead  of  the  normal  angles 
and  flattened  curves  of  the  labial  surfaces,  the  incisors  may  have 
a  roughly  rounded  and  stunted  appearance.  The  incisal  edge  of 
the  tooth  is  narrower  than  its  neck.  The  enamel  at  this  edge  is 
irregularly  and  badly  formed;  but  there  is  a  semblance  of  the  three 
enamel  tubercles  found  normally.  The  middle  tubercle,  being  com- 
posed of  defective  enamel,  is  soon  lost  by  abrasion,  causing  the 
tooth  to  have  a  notched  appearance  (Fig.  147).     Stein  quotes  an 

'  Dental  Cosmos,  July,  1913,  p.  693. 


MACROSCOPIC  MALFORMATIONS 


161 


old  authority  as  having  seen  one  central  notched  and  the  other 
normal.     The  first  permanent  molars  are  often  exceedingly   corru- 

FiG.  146 


Pitted  and  fringed  teeth,  some  of  them  carious  at  the  incisal  edges.    Specimen  in 
museum  of  Philadelphia  Dental  College. 

Fig.  147 


Hutchinson's  teeth.  Hypoplasia.  Two  upper  centrals  notched  and  contracted. 
Characteristically  undeveloped  upper  jaw.  From  a  hereditary  syphilitic,  aged 
twelve  years. 


gated  and  pitted,  the  pits  extending  into  the  dentin.     These  pits 
often  decay,  the  points  are  broken  or  worn  away,  sometimes  leaving 
a  discolored,  often  black  surface.     (Fig.  151.) 
11 


162     MALFORMATIONS  AND  ANOMALIES  OF  THE   TEETH 

In  an  exhaustive  treatise  upon  this  subject,  Cavallaro^  has  shown 
that  the  pitted  cuspal  deformity  of  the  first  molars,  the  notched 

Fig.  148 


^^*^- 


Hypoplasia  of  enamel,  showing  arrested  stratification;  dentine  shows  effects  of  hypo- 
plasia at  interglobular  spaces.    (Hopewell-Smith.) 


incisors  of  Hutchinson,  and  the  dj^strophic  cusps  of  canines  in  the 
permanent  set,  as  well  as  similar  effects  occurring  in  the  temporary 


Fig.  150 


Syphilitic  teeth  in  upper  and  lower  jaws 
as  they  appear  when  recently  erupted. 


The  teeth  of  hereditary  syphilis  at 
maturity. 


set,  are  the  stigmata  of  hereditary  syphilis,  either  direct  or  in  the 
second  generation.  He  found  the  treponema  pallidum  in  the  dental 
follicles  of  syphilitic  fetuses. 


1  Dental  Cosmos,  1908. 


MACROSCOPIC  MALFORMATIONS 


163 


He  calls  attention  to  the  possible  effect  upon  the  first  molar  enamel 
(developing  before  birth)  alone,  as  indicating  the  cessation  of  tre- 
ponemal activity,  though  the  incisor  enamel  (developing  after  birth) 
is  usually  affected.  The  cuspid  (developing  still  later)  may  not  be 
affected;  which  shows  a  cessation  of  germ  activity  between  incisor 
and  cuspid  development.  The  dental  stigmata  may  thus  occur  in 
the  absence  of  the  under-developed  body  and  other  physical  charac- 
teristics of  syphilis,  though  these  may  also  be  in  evidence,  as  well  as  a 
history  or  evidence  of  more  or  less  active  manifestations  of  syphilis.^ 

Fig.    151 


Semidiagrammatic  representation  of  a  systematized  hypoplasia  of  several  kinds  of 
upper  and  lower  teeth.  The  general  systemic  disturbance  which  must  have  caused 
these  stigmata,  commenced  about  the  twenty-fifth  week  of  intra-uterine  life  and  con- 
tinued up  to  about  the  fourth  month  after  birth.  (The  third  molars  omitted.) 
(Stein.) 


Stein^  argues  that  as  the  stigmata  are  bilateral  and  symmetrical, 
they  could  not  have  been  produced  by  causes  acting  locally,  but 
that  the  general  disturbance  of  metabolism  affecting  the  develop- 

1  No  matter  what  conviction  a  dentist  has  that  these  dystrophies  are  of  syphiUtic 
origin,  he  must  be  cautious  regarding  the  expression  of  his  opinion.  Even  the  thought- 
less leaving  of  a  copy  of  this  volume  upon  the  desk  from  which  it  was  picked  up  and 
this  chapter  seen  by  a  lady  patient,  produced  questions  of  a  very  embarrassing  character, 
regarding  certain  defects  in  her  child's  teeth.  Unfortunately,  Cavallaro's  investi- 
gations do  not  take  sufficient  cognizance  of  the  possible  intervention  of  other  exanthe- 
mata, either  in  the  subject  or  mother;  for  example,  in  his  Case  XX,  a  girl,  aged  four- 
teen years,  hereditary  syphilitic  showing  transverse  grooves  in  the  teeth,  the  effects 
are  attributed  to  syphilis.  The  child  may  easily  have  had  other  complications,  such 
as  measles.  Stein  excludes  rachitis,  variola,  scarlatina,  diphtheria,  typhoid  and 
rheumatism  as  very  rare  possible  causes  of  the  hypoplasia. 

2  Dental  Cosmos,  July,  1913,  p.  695. 


164     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

mental  organs  of  the  teeth  causes  interference  with  the  functions 
of  such  of  them  as  should  be  actively  developing  tooth  structure. 

While  to  syphilis,  may  now  be  accredited  much  of  the  pittings  upon 
teeth,  the  history  of  an  attack  of  one  of  the  exanthemata,  such  as 
scarlet  fever  or  measles,  at  a  certain  age  corresponding  to  the  devel- 
opment of  the  particular  part  of  the  tooth  which  has  undergone 
hyperplasia  makes  it  rational  to  accredit  the  effect  to  such  exanthema. 
Measles  often  causes  characteristic  eruptions  in  the  mucous  mem- 
brane of  the  mouth  and  pharynx,  and  could  easily  affect  the  dental 
follicle.  If  the  disease  and  the  effect  do  not  correspond  chronologic- 
ally they  should  not  be  related.  Syphilis  is  in  a  way,  an  exanthem- 
atous  disease  of  chronic  nature. 

In  hereditary  syphilitics,  Cavallaro  found  the  following  dental 
stigmata:  Hypoplastic  defects  of  systematic  character  with  predi- 
lection for  the  central  incisor  forming  the  notched  incisor  or  Hutchin- 
son's tooth,  and  also  cuspal  defects,  white  sulci,  white  marks,  delay 
of  development  and  eruption,  dental  infantilism,  microdontism, 
amorphism,  persistence  of  deciduous  teeth,  cuspal  defects  of  decidu- 
ous teeth,  especially  the  second  molar,  anomalies  of  structure, 
shape,  number,  direction,  arrangement,  and  color,  vulnerability  of 
the  dental  system,  ectopia,  total  or  partial  absence  of  teeth,  wearing 
away,  premature  caries,  premature  loss  of  teeth,  space  between  teeth, 
diastema.  Also  the  following  maxillary  stigmata:  malocclusion, 
defective  articulation  of  the  dental  arches,  prognathism,  ogival 
palate  and  cleft  palate. 

Stein  offers  the  following  perhaps  more  clearly  expressed  classi- 
fication : 

"1.  Multiple  disseminated  stigmata  of  the  teeth,  both  in  the 
maxilla  and  the  mandible. 

2.  Symmetrical  stigmata  here  and  there  upon  homologous  teeth. 

3.  Systematized  stigmata  at  the  same  level  on  teeth  of  the  same 
kind,  but  at  a  different  level  on  different  kinds  of  teeth. 

The  most  characteristic  stigmata  of  the  teeth  of  heredosyphilis 
are: 

1 .  Hypoplasia  of  the  four  first  molars. 

2.  A  systematized  hypoplasia  upon  the  several  upper  and  lower 
teeth. 

3.  Hutchinson's  teeth.  Microdontism  and  non-replacement  of 
deciduous  teeth  due  to  arrested  development  of  the  permanent 
successors  are  regarded  by  Stein  as  stigmata." 

Black^  states  that  any  malnutrition,  even  a  burn,  typhoid  fever, 

»  Dental  Review,  1906. 


MACROSCOPIC  MALFORMATIONS  165 

a  spasm,  etc.,  may  mark  teeth  as  a  nail  may  be  grooved.  He  claims 
to  have  seen  Hutchinson's  teeth  without  history  of  taint. ^ 

As  it  ordinarily  causes  embarrassment  to  question  dental  patients 
regarding  syphilis,  the  Wassermann  reaction  may  be  resorted  to 
if  a  diagnosis  be  needed. 

Stein  states  that  the  Wassermann  may  be  positive  or  negative 
in  heredosyphilis. 

The  point  at  which  the  arrested  development  would  occur,  is  that 
part  under  development  at  the  time  the  nutritional  or  infective  dis- 
turbance occurs.  When  several  developing  teeth  are  attacked,  the 
centrals  are  marked  nearer  the  neck  than  laterals,  and  these  nearer 
than  cuspids.  The  first  molars  are  often  occlusally  defective,  as  well 
as  incisors,  and  sometimes  the  incisors  have  only  white  or  brown 
spots  instead  of  the  incisal  notch;  bicuspids  are  only  rarely  marked. 

Fig.   152 


Hutchinson's  teeth,  cuspal  atrophy  of  canines  and  molars.    Multiple  sulciform  erosions 

Diastema.      (Cavallaro.) 

A  lack  of  development  of  the  anterior  portion  of  the  upper  jaw 
has  been  noted  in  a  number  of  cases  clearly  syphilitic  (Fig.  147). 
It  has  been  noted  that  not  all  syphilitic  children  present  these  dental 
appearances;  and,  again,  appearances  said  to  be  identical  with  them 
are  observed  in  children  said  not  to  be  syphilitic;  nevertheless,  the 
presence  of  such  teeth  is  usually  regarded  as  a  valuable  diagnostic 
sign  of  hereditary  syphilis.  The  existence  of  interstitial  keratitis 
and  of  chronic  catarrh  of  the  middle  ear,  in  connection  with  Hutchin- 
son's teeth  are  held  to  be  positively  diagnostic  signs  of  hereditary 
syphiHs  (Hare).     (See  Sabouraud,  p.  181.) 

Oberwarth,^  in  a  synopsis  of  associate  symptoms,  mentions 
central  deafness,  chronic  hydrarthrosis  of  the  knee,  periostitis  of 

1  Dental  Digest,  1904. 

2  Review  by  Dental  Cosmos,  1908,  p.  179. 


166     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

the  tibia,  tumefaction  of  the  spleen  and  liver,  radiating  cicatrices  of 
the  lips,  adenopathies,  ozena,  and  deformities  of  the  bridge  of  the 
nose,  cutaneous  gummata,  hemoglobinuria,  and  cerebral  phenomena 
as  possibilities  deduced  from  a  study  of  his  known  cases  of  hereditary 
syphilis. 

In  605  hereditary  syphilitics  observed  by  Sidler,  Huguenin,  and  the 
Fourniers,  the  stigmata  averaged  as  follows:  ocular,  50  per  cent.; 
dental,  43  per  cent.;  aural,  16  per  cent.^ 

Therapeutics  based  upon  such  a  diagnosis  are  followed  by  better 
results,  as  a  rule,  than  when  the  general  indication  is  ignored.  The 
boy  from  whose  mouth  a  model  (Fig.  147)  was  obtained,  had  inter- 
stitial keratitis  in  the  left  eye,  chronic  nasal  catarrh,  and  a  somewhat 
flat  development  of  the  nasal  bones. 

Tomes  favors,  and  adduces  evidence  to  support  the  contention  of 
Hutchinson,  that  honeycombed  incisal  edges  of  incisors  and  cuspids 
and  occlusal  surfaces  of  first  molars  are  indicative  of  mercurials 
administered  in  early  childhood. 

Pitted,  grooved,  or  otherwise  malformed  teeth  may  decay  some- 
times so  badly  as  to  produce  a  black,  slimy  appearance  almost 
loathsome  to  view.    In  other  cases  surprisingly  little  caries  develops. 

Treatment. — If  slightly  pitted,  silicate  cement  fillings  are  preferable. 
Single  pits  collect  stains  which  are  not  removed  by  the  brush.  It  is 
well  to  concave  these  with  a  small  finishing  bur,  and  to  furnish  the 
patient  a  sharply  pointed  stick,  for  cleansing  with  tooth  powder  or 
pumice.  In  some  cases,  grinding  off  the  rough  incisal  edge  is  sufficient; 
in  other  cases  the  teeth  may  require  to  be  drawn  down  after  this 
procedure,  or  porcelain  inlays  may  be  used  to  restore  the  incisal 
edges.  In  the  extremely  disagreeable  cases  above  mentioned,  some 
form  of  crowning  must  be  resorted  to.  Fig.  153  exhibits  a  restoration 
of  the  case  shownti  in  Fig.  145.  For  molars  which  tend  to  decay, 
amalgam  or  copper  cements,  white  or  black,  are  useful  and  when  the 
cavities  are  broad  or  numerous  a  short  gold  crown  may  be  fitted. 

Agenesia  of  Enamel. — Cases  are  observed  where  there  has  been  a 
formative  crisis  to  the  extent  of  having  apparently  no  enamel  what- 
ever formed  over  the  occlusal  section  of  the  crown,  its  deposit  on 
the  remainder  of  the  crown  being  quite  normal  (Fig.  142). 

D.  B.  Freeman-  records  the  case  of  an  individual,  aged  twenty-six 
years,  whose  teeth  anterior  to  the  second  molar  were  entirely  devoid 
of  enamel.  The  condition  was  hereditary;  it  appeared  in  both 
brothers  and  sisters,  and  could  be  traced  back  for  three  generations. 


1  Cavallaro:  Dental  Cosmos,  1909. 

2  Guilford;  American  System  of  Dentistry,  vol.  iii. 


MACROSCOPIC  MALFORMATIONS 


167 


Hopewell-Smith^  claims  that  teeth  apparently  de^'oid  of  enamel 
have,  in  all  cases  examined  by  him,  had  attenuated  enamel  upon 
them.    This  would  also  be  classified  as  hypoplasia. 

Black^  has  described  the  teeth  of  a  man,  aged  twenty-seven  years, 
as  having  enamel  of  an  opaque,  paper-white  appearance,  as  readily 
cut  as  a  slate  pencil,  and  with  dentin  of  ordinary  consistence.  The 
teeth  presented  little  caries.  He  also  described  the  temporary  teeth 
of  a  child  as  all  without  trace  of  enamel,  the  dentin  soft,  bendable 
in  any  direction,  "udth  production  of  pain,  and  penetrable  with  a 
sharp  explorer  (agenesia  of  enamel). 

Hopewell  Smith^  has  observed  an  entire  absence  of  crowns,  not 
due  to  wear  or  caries,  both  on  upper  and  lower  teeth,  in  four 
generations  in  one  family.  Therefore,  they  are  cases  of  extreme 
hereditary  agenesia  of  the  crowns  and  are  evidence  of  a  possible  tooth 
development  independent  of  an  enamel  organ. 

Fig.  153 


^ 


Same  as  Fig.  145,  with  Land  jacket  crowns  placed  over  anterior  teeth.     (W.  A.  Capon.) 

Anomalies  of  Development  not  of  Dystrophic  Character. — This 

subdivision  will  include  all  variations  in  size,  form,  number  and 
development,  clearly  due  rather  to  hereditary  individual  peculiarly  of 
development  or  to  accident  rather  than  to  nutritional  or  infective 
disturbance  of  developmental  organs. 

Variations  as  to  Size. — It  is  patent  to  the  most  casual  observer 
that  the  teeth  vary  as  to  size.  Comparisons  in  this  direction  are 
made  by  an  examination  of  the  upper  central  incisors.  Fig.  154 
shows  nearly  the  extremes  of  observable  sizes;  Guilford^  points  out 
that  excessively  large,  central  incisor  crowns  are  usually  supported 
by  abnormally  small  conical  roots.    Marked  giantism  of  the  central 


'  Histology  and  Patho.  Histology  of  the  Teeth. 

2  Dental  Cosmos,  June,  1908. 

3  Ibid.,  August,  1913,  p.  781. 

^  American  System  of  Dentistry,  vol.  iii. 


168     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 


incisors  usually  occurs  in  pairs,  the  other  teeth  being  of  normal  size. 
On  the  other  hand,  dental  giantism  of  less  degree  may  involve  all 
of  the  teeth  of  a  denture.  The  molar  teeth  are  occasionally  of 
enormous  size,  the  bicuspids  rarely  so,  and  the  cuspids  next  in  fre- 
quency to  the  molars  as  to  the  occurrence  of  giantism.  Guilford 
observes  that  giantism  of  the  cuspid  crowns,  unlike  that  of  the 
central  incisors,  is  usually  accompanied  by  an  increased  size  of  root. 
He  mentions  the  case  of  a  cuspid  measuring  an  inch  and  one-half 
in  length  from  tip  to  tip. 

Fig.  154 


Dwarf  Teeth. — Deficiency  in  size  is  of  more  common  occurrence 
than  excessive  size.  It  appears  to  occur  more  frequently  with  the 
upper  third  molars  and  upper  lateral  incisors  than  with  any  other 
teeth.  Fig.  155  shows  the  extremes  in  size  between  two  perfectly 
formed  lower  third  molars.  The  stunting  of  these  and  of  other  teeth 
is,  however,  usually  associated  with  such  an  aberration  of  outward 
form  that  most  dwarf  teeth  must  be  considered  as  abnormal  in  form 
as  well  as  in  size.  The  writer  has  seen  a  supernumerary  with  crown 
and  root  together  measuring  one-eighth  inch. 


Fig.  155 


Tusk-like  permanent  central  incisors;  temporary  teeth  retained  on  either  side, 
aged  twenty- five  years. 


Female, 


A  central  incisor,  or  more  frequently  a  lateral  incisor,  may  have 
a  conical  crown,  as  shown  in  Fig.  155.    The  condition  may  be  double. 

Upper  third  molars  frequently  consist  of  but  a  single  cone,  diminu- 
tive in  size;  at  times  a  crater-like  crown  is  formed  by  a  series  of  small 
cones  about  a  central  pit. 


MACROSCOPIC  MALFORMATIONS 


169 


Treatment. — The  Land  jacket  crown  is  very  useful  in  modifying 
the  cone  into  a  typical  tooth  form  (Fig.  156). 


Fig.  156 


Conical  lateral  incisor  transformed  by  porcelain  crown. 

Fusion  of  Teeth. — Two  or  more  teeth  may  be  united  during  the 
process  of  development.  The  union  may  occur  (1)  by  the  crowns, 
(2)  by  the  roots  alone,  and  (3)  by  both  cro"^Tis  and  roots. 

1.  Fused  teeth  united  by  the  crowTis  alone  have  not  been  shown. 
The  nearest  approach  to  it  is  the  case  illustrated  by  Tomes,  in  which 
two  central  incisors  have  fused  by  union  of  the  crown  portions 
and  one-fifth  of  the  root  portions  of  the  two  teeth  (Fig.  157). 
Such  teeth  would  have  dentin  common  to  both  crowns  at  the  point 
of  union,  the  enamel  being  reflected  over  the  outside  of  the  common 

Fig.   157 


Lingual  view.  Labial  view. 

Fusion  of  two  permanent  upper  central  incisors  by  their  crowns  and  a  portion  of  the 

roots.     (Tomes.) 


dentinal  mass,  according  to  the  scheme  shown  in  the  diagram  Fig. 
161,  B.  The  pulp  may  be  common  to  the  two  teeth  in  the  crown. 
Of  course,  the  root  pulps  are  separate. 

The  condition  is  a  record  of  the  fact  that  prior  to  dentification  the 
papillae  and  enamel  organs  of  the  two  teeth  have  coalesced  at  some 
point.  This  must  have  occurred  at  an  early  period,  perhaps  even 
during  the  descent  of  the  cords  into  the  jaw.  When  it  is  considered 
that  the  two  central  incisors  are  contained  in  two  separate  inter- 
maxillary bones,  the  rarity  of  such  a  union  and  in  such  a  manner 
may  be  appreciated.    I  have  seen  such  a  union  between  a  right  lower 


170     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

central  and  lateral  incisor,  in  the  mouth.  Recession  of  the  gum  per- 
mitted a  view  of  the  cervical  conformation.  This  case  also  disposes 
of  the  question  raised  as  to  whether  fusion  can  pass  the  mesial  line. 
Fig.  158  also  shows  a  fusion  of  lower  centrals. 

Fig.  158 


Fused  centrals.     (Batcheff,  Dental  Cosdqos.) 

2.  Those  teeth  united  by  fusion  of  the  roots  have  a  common  dentin 
at  the  point  of  union,  with  cementum  reflected  over  that.  The  pulp 
is  common  to  the  two  teeth  at  the  point  of  fusion. 

Fig.  159 


r 


^ 


a  b  c  d  i 

a,  fusion  of  two  molars  at  the  roots — two  pulp  cavities,  one  foramen;  b,  c,  fusion  of 
supernumerary  teeth  roots  to  buccal  roots  of  upper  molars,  pulp  canal  common  where 
probes  cross;  d,  view  of  resorbed  root  end  of  two  fused  temporary  teeth;  e,  concres- 
cence by  bypercementosis. 


In  the  specimen  shown  in  Fig.  159  at  a  there  is  but  one  apical 
foramen.  In  that  shown  at  b  and  c  there  is  but  one  foramen  for  the 
two  fused  portions  of  pulp,  though  the  other  canals  have  their  usual 
foramina.  These  cases  evidence  an  accidental  coalescence  of  pulps 
after  much  independent  root  formation. 

3.  Fusion  throughout  both  crocus  and  roots  have  the  same  charac- 


MACROSCOPIC  MALFORMATIONS 


171 


Fig.  160 


Fused  denticles. 


teristics  as  the  others,  combined  in  the  one  specimen  (Fig.  162).    The 
diagram  (Fig.  161)  shows  the  scheme  for  the  crowTi  and  root. 

Fig.  166  shows  specimens  of  fusion  in  both  the 
upper  and  lower  jaws.  It  occurs  also  with  the 
temporary  teeth  (Fig.  167).  Fig.  160,  A  shows  a 
very  rare  condition,  the  fusion  of  the  temporary 
central,  lateral,  and  cuspid  of  one  side  (triple  fusion). 
Fusion  is  evidently  an  abnormality  of  develop- 
ment, dependent  upon  coalescence  of  formative 
organs  at  some  point,  and  is  most  likely  to  occur 
where  the  adjacent  tooth  follicles  have  least  anatom- 
ical separation  from  their  fellows.  The  roots  of  fused  temporarj'^ 
teeth  are  resorbed  as  usual  (Fig.  159,  d). 

No   particular  treatment  is  re- 
^  Fig.  161  ^  quired   unless  the  mass   in   some 

way  causes  interference  with  func- 
tion, which  is  unusual.  The  teeth 
having  a  common  pulp,  no  attempt 
should  be  made  to  divide  them. 


Fig.  162 


A,  diagram  of  a  case  of  triple  fusion, 
showing  crowns  with  independent  in- 
cisal  edges  and  pulps;  but  otherTvise 
fused  into  one  crown  with  one  pulp; 
B,  transverse  section  of  same,  sho\\'ing 
common  pulp  ca^dty  and  common  den- 
tin overlaid  by  enamel  (or  cementum). 
From  a  perfect  specimen  in  the  editor's 
collection.    (Enlarged.) 


Permanent  central  and  lateral  incisors  of 
the  upper  jaw,  united  throughout  the  whole 
length  of  the  teeth.      (Tomes.) 


Fusions  are  most  common  between  the  anterior  teeth  of  each  set  and 
between  the  second  and  third,  or  third  and  fourth  (supernumerary), 
permanent  molars.  It  has  rarely  been  noted  in  bicuspids,  presumably 
because  these  teeth  lie  in  the  bifurcations  of  the  temporary  molars, 
but  Fig.  163  shows  a  case  of  fusion  of  a  bicuspid  and  molar,  the 
only  one  ever  brought  to  the  writer's  attention. 

Concrescence  of  Teeth. — Concrescence  of  teeth  is  their  union  after 
the  tooth  is  formed ;  it  is  evident,  therefore,  that  the  union  can  only 
be  caused  by  fusion  of  cementum.  This  means  that  during  the 
formative  and  eruptive  period,  or  after  eruption,  the  bony  partition 
between  the  teeth  disappears,  and  that  their  pericementi  become 


172     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

united,  receding  from  the  line  of  compression  as  cementum  is 
deposited  between  and  joining  the  roots.  The  united  teeth  show 
evidences  of  hypercementosis  at  points  other  than  the  point  of  union 
(Fig.  159,  e,  and  Fig.  169).  At  times  the  roots  of  the  same  tooth 
undergo  either  fusion  or  concrescence. 

Fig.  163 


Fused  bicuspid  and  molar. 


Fig.  164 


During  the  eruption  of  the  third  molars,  particularly  the  upper, 
temporary  lack  of  space  for  the  eruption  of  the  crown  may  cause 
resorption  of  the  bone  covering  the  roots  of  the  second  molar,  and 
fusion  of  the  formative  pericementum  of  the  third  molar  with  that 
of  the  second  occurs;  a  deposition  of  cementum  then  binds  the  teeth 
together,  preventing  the  eruption  of  the  third  molar.  More  than 
two  teeth  may  be  thus  united.  The  lower  third  molar  rarely  pre- 
sents its  roots  to  those  of  the  second  molar;  the 
contrary  presentation  is  the  rule. 

In  at  least  one  case,  the  crown  of  the  upper 
third  molar  was  partly  erupted  when  concres- 
cence occurred.  Retained  in  this  situation,  the 
crown  decayed  away,  necessitating  extraction; 
the  second  molar  came  away  with  it.  The 
condition  also  occurs  apart  from  the  jcruptive 
process.  Excessive  hypercementosis  upon  the 
roots  of  individual  teeth  may  finally  result  in 
their  union  (Fig.  159,  e). 
The  only  treatment  required  for  concrescence  is  that  indicated 
for  impaction  or  hypercementosis  (which  see) . 

The  tough  fibrous  gum  tissue  or  pericementum  has  caused  two 
temporary  teeth  to  be  extracted  together  at  times  (Fig.  168). 

Pont  cites  a  case  of  attachment  of  a  lower  first  molar  distal  root 
to  the  mesial  root  of  the  second  molar  by  a  strong  fibrous  ligament, 
2  mm.  in  diameter,  and  causing  fracture  and  removal  with  the  first 
molar.    There  is  also  sometimes  a  firm  fibrous  pericemental  attach- 


Fusion  of  a  super- 
numerary tooth,  with 
an  upper  third  molar. 


MACROSCOPIC  MALFORMATIONS 


173 


ment  between  a  tooth  and  the  alveolar  process  or  bone.     In  one 
case  a  portion  of  the  antral  iBoor  was  torn  out  with  the  apical  tissue. 


Fig.   165 


Geminous  upper  laterals  with  common  palp.    Practice  of  Dr.  Varney  Barnes. 
(Radiograph  by  E.  Ballard  Lodge.) 

Fig.  170  illustrates  a  remarkable  case  of  combined  fusion, 
concrescence,  flexion,  and  hj^jercementosis.  In  this  case  two 
abnormal  third  molar  crowns  were  first  formed.  The  roots  were 
fused  during  development,  though  individual  single-pulp  canals 
were  formed,  which  joined  to  form  one  foramen.  The  lapped  condition 

Fig.  166 


A,  fusion  of  upper  geminous,  permanent  laterals;  B,  fusion  of  lower  right  permanent 
central  and  lateral  incisions. 


of  the  roots  was  due  to  pulp  flexion  previous  to  root  deposition.    The 
carious  second  molar  roots  all  became  hypercementosed  and  probably 


174     MALFORMATIONS  AND  ANOMALIES  OF  THE   TEETH 

from  non-occlusion,  or  the  widespread  irritation  aroused  by  the  fused 
teeth  in  descent.  As  the  fused  teeth  erupted,  they  presented  one 
root  to  one  root  of  the  second  molar. 

Fig.  167 


Fusion  of  upper  temporary  teeth.     Double  fusion  of  lower  temporary  lateral  and 

cuspid. 


Fig.  168 


Fig.  170 


Attachment  of  temporary  teeth  by  their 
pericemetin. 


Fig.  169 


\jiiM~^ 


Concrescence.    Third   upper  molar  imprisoned 
between  the  roots  of  the  second  molar. 


Case  of  fusion  of  two  abnormal 
molars  and  concrescence  with  the 
root  of  a  right  upper  second  molar 
.(restored  for  illustration.)  Pulp 
canals  shown  in  outline.  Common 
apical  foramen  (enlarged.)  (From 
author's  collection.) 


MACROSCOPIC  MALFORMATIONS  175 

The  junction  of  these  occurred  as  the  result  of  formations  of  cementum 
(concrescence) .  The  \\'idely  open  crater-Hke  pit  in  each  crowoi  shows 
the  persistence  of  soft  tissue  (enamel  organ)  at  that  point,  and  a 
lack  of  enamel  development  there. 

Mechanical  Union  of  Teeth. — Teeth  upon  extraction  are  occasion- 
ally found  united  by  alveolar  bone  which  is  locked  between  the 
roots  of  the  two  or  more  teeth  and  prefers  to  fracture  elsewhere. 
Occasionally  a  sequestrum  contains  several  teeth  (Fig.  72). 


Double  gemination  of  upper  permanent  lateral  incisors. 

Gemination  of  Teeth  (Twin  Teeth). — This  term  has  been  used  by 
Tomes  in  the  sense  of  union  of  teeth,  but  it  is  perhaps  better  used 
to  designate  supplemental  teeth  of  the  same  class.  In  twin  teeth, 
the  enamel  organ  of  a  permanent  or  temporary  tooth  is  duplicated, 
in  all  probability,  two  buds  arising  from  the  cord  or  band,  as  the 
case  may  be. 

In  gemination,  one  of  the  teeth  formed  is,  of  course,  a  supernu- 
merary tooth,  but  in  some  cases  both  are  typical  teeth  (Fig.  171). 
The  second  germ  may  develop  an  atypical  tooth  or  one  but  slightly 
abnormal  in  form.  The  geminous  teeth  may  undergo  fusion,  as  seen 
in  Figs.  165  and  166,  A. 

Duplication  of  the  Pulp  Cavity. — Hopew^ell-Smith  calls  attention 
to  a  case  of  an  upper  permanent  central  incisor  containing  two  pulp 
cavities  in  the  coronal  portion,  probably  an  interrupted  gemination. 

Tooth  Inclusion. — Bens  in  Bente.  These  terms  refer  to  the  inclu- 
sion of  one  tooth  withm  another. 

Cohen^  attributes  the  first  description  of  the  anomaly  to  Busch 

1  Dental  Cosmos,  March,  1919. 


176     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

and  seems  to  regard  it  with  him  as  one  tooth  structure  built  circu- 
larly around  another.  The  peculiarity  noted  is  that  the  primary 
tooth  has  a  root  with  cementum  outside  and  dentin  inside  while  the 
dens  in  denie  has  cementum  inside  and  dentin  outside.  He  offers 
some  illustrations  which  are  particularly  interesting  as  showing  the 
enamel-covered  crown  of  a  supernumerary  tooth  penetrating  the 
unfinished  apical  foramen  of  the  primary  tooth. 


Fig.  172 


Kirk,  Dens  iu  Dente. 


Lingual  and  buccal  half  of  the  matured  dens  in 
dente.     (Cohen.) 


Kirk/  in  describing  the  anomaly  shown  in  Fig.  172,  theorizes 
*'  that  it  arose  from  an  invagination  of  a  portion  of  the  dental  follicle 
including  some  portion  of  the  enamel  organ  on  the  same  principle 
that  dermoid  cysts  arise  from  invagination  and  inclusion  of  portions 
of  blastoderm  within  the  body  of  the  organism." 

Inasmuch  as  the  descent  of  supernumeraries  formed  outside  of 
teeth  upon  teeth  in  the  mouth  is  known  and  their  occasional  pro- 
duction of  resorption  of  permanent  roots  by  such  descent  is  known 

>  Dental  CpgroPS,  June,  1918. 


MACROSCOPIC  MALFORMATIONS  177 

and  Cohen  illustrates  one  at  the  root  apex  apparently  entering  it  and 
Fig.  172  shows  one  completely  formed  and  lying  to  all  intents  free 
in  the  pulp  caidty  and  surrounded  by  space  for  pulp  tissue,  the 
writer  is  mclined  to  believe  that  a  supernumerary  has  descended 
squarely  upon  the  open  foramen  of  an  undeveloped  primary  or  pre- 
ceding tooth  and  has  penetrated  the  wide  pulp  tissue  causing  it  to 
bulge  upon  the  sides  and  around  it.  In  the  case  in  Fig.  172  this 
must  have  occurred  early  in  root  development  of  the  primary  tooth 
at,  say  nine  years  of  age. 

The  surrounding  pulp  and  its  outer  follicle  wall  then  formed  a  very 
large  root  which  went  on  to  almost  completion. 

To  account  for  the  dentin  outside  cementum  inside  of  the  root  of 
the  secondary  tooth  we  may  theorize  that  its  crown  pushed  down  the 
follicle  wall  normally  around  all  formative  pulps  (papilla),  so  that 
the  secondary  tooth  was  surrounded  by  a  soft  tissue  arranged  thus: 
follicle  wall  inside,  pulp  tissue  outside.  The  calcification  would  then 
be  as  claimed  by  Cohen,  though  the  pulp  of  the  supernumerary  is 
not  thus  taken  into  account.  Even  in  odontomes  the  calcific  forma- 
tions are  held  to  result  from  the  respective  formative  tissues  and 
while  the  pulp  of  the  secondary  tooth  might  possibly  form  cement- 
like structure  under  irritation  (see  Pulpitis) ,  it  is  probable  the  follicle 
wall  and  pulp  in  some  mamier  became  arranged  as  suggested.  It 
would  be  interesting  to  know  if  Kirk's  tooth  had  this  histological 
arrangement. 

Harrower's  case  (Fig.  49)  shows  a  tooth  inclusion  due  to  explain- 
able forces,  i.  e.,  a  pushing  up  of  the  permanent  crown  into  the  pulp 
of  the  temporary  tooth  which  in  turn  has  become  an  absorbent  organ 
and  hollowed  out  the  temporary  crown.  Again  Fig.  172  shows  what 
looks  much  like  secondary  formation  just  below  the  tip  of  the  super- 
numerary crown  which  is  evidence  of  interference  with  pulp  function. 
Raper  illustrates  a  radiograph  of  a  similar  anomaly  from  the  practice 
of  Dr.  Van  Woert. 

The  formation  of  so  much  root  as  Cohen's  case  shows  before  the 
supernumerary  is  included  seems  to  prove  that  the  inclusion  is  acci- 
dental and  not  a  heterogeneous  arrangement  of  germs  or  tissues. 

Dilaceration. — By  dilaceration  is  meant  a  displacement  of  a  formed 
portion  of  a  tooth  in  such  a  manner  as  to  change  its  relative  position 
to  the  soft  parts  engaged  in  its  development,  the  development  then 
being  continued  in  the  new  relation.^  For  example,  an  accident  to 
a  temporary  tooth  occurs  and  the  force  may  displace  the  partially 
formed  permanent  crown,  altering  its  relation  to  the  enamel  organ 

'  Tomes. 
12 


178     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

and  papilla  engaged  in  its  formation.  The  balance  of  the  crown 
may  be  formed  in  the  new  situation  and  be  of  fairly  perfect  or  of 
imperfect  structure  (Fig.  174).  This  is  most  likely  to  occur  with 
the  anterior  teeth,  especially  when  a  temporary  tooth  is  driven  into 
the  alveolar  process,  its  root  in  turn  displacing  the  permanent  tooth, 
thus  twisting  its  relation  to  its  formative  organs.  I  have  a  beautiful 
specimen  of  a  fossilized  tooth  from  a  Florida  Indian  mound  showing 
this  condition.^ 


Fig.  174 


Pulp  hernia  and  flexion,  mesiodistal 
section:  E,  enamel,  distal  section  in  the 
bifurcation  of  the  roots,  flexion  of  enamel 
organ;  D,  dentin;  C,  C ,  cementum;  PC, 
pulp  cavity,  flexion  of  pulp  with  hernia  or 
at  least  abnormal  enlargement  before  root 
formation;  F,  large  apical  foramen;  B  of 
R,  bifurcation  of  the  roots.  (From  a  speci- 
men, enlarged.)  The  whole  is  a  radicular 
odontoma. 

Fig.   176 


DUaceration.  Shows  fold  iii  the  labial 
enamel  and  cervical  dentin.  (After  von 
Wunschheim.2) 


Enamel  excrescences.     (Salter.) 


Flexion. — Flexion  means  the  movement  of  one  of  the  formative 
organs  of  a  tooth  away  from  its  normal  relation  to  the  hard  part  it 
is  developing.  The  soft  part  has  its  position  altered,  the  hard  part 
remaining  in  correct  position.  Subsequent  formations  therefore 
have  an  abnormal  relation  to  the  previously  formed  portions  of  the 
tooth. 


1  Kindly  presented  by  Dr.  Simpson,  of  Kissimee. 

2  G.  von  Wunschheim:  Fracturen.  Infraktionen  und  Knickungen  der  Zahne. 


MACROSCOPIC  MALFORMATIONS 


179 


As  an  example  of  flexion,  a  portion  of  the  enamel  organ  of  a  tooth 
may  be  displaced  and  in  its  new  relations  may  form  enamel  in  an 
unusual  situation,  as,  for  example,  upon  the  side  or  neck  of  the  root 
(see  enamel  nodule)  or  even  in  the  bifurcation  or  on  the  apex  of  the 
root  (Figs.  175  and  178).  Again,  it  is  probable  that  lack  of  space 
may  cause  deflection  of  a  pulp  engaged  in  root  formation,  a  curved 
root  being  the  result  (Fig.  184).  The  pericementum  (follicle  wall) 
moves  with  the  pulp  in  these  cases. 

.  Unusual  Locations  of  Enamel. — That  during  development,  the  enamel 
organ  or  portions  of  it,  may  assume  an  abnormal  relation  to  the  pulp, 
is  evidenced  by  odontomes.  Apart  from  these,  there  are  evidences 
seen  in  teeth  which  show  that  portions  of  the  enamel  organ  may 
become  detached  from  the  main  organ,  and  develop  enamel  in  unusual 
situations.  Thus  columns  of  enamel  may  penetrate  the  body  of  the 
dentin,  i.  e.,  the  enamel  organ  has  lain  within  the  papilla. 


Fig.  177 


Fig.   178 


Lower  molar  with  enamel  nodule 
connected  to  the  enamel  of  crown  by 
a  ridge  of  enamel. 


Five-rooted  upper  molar,  cap  of  enamel 
on  end  of  one  root.  Possibly  a  fusion  of 
a  supernumerary. 


A  small  nodule  or  cap  of  enamel  overlying  dentin,  and  itself  over- 
lapped at  the  edges  by  cementum  (Fig.  179),  may  be  found  upon  the 
root  of  a  molar,  usually  upon  the  side  of  an  upper  third  molar  at  a 
point  about  one-eighth  inch  from  the  cervical  margin  of  the  crown 
enamel;  but  one  may  be  one-half  inch  distant  from  the  enamel  mar- 
gin. A  thin  ridge  of  enamel  sometimes,  though  not  usually,  seen 
connecting  them,  indicates  the  nodule  to  have  been  formed  by  a 
detached  portion  of  the  original  enamel  organ  (Fig.  177).  This  forma- 
tion is  known  as  an  enamel  nodule.  It  may  occur  upon  a  lower 
molar,  though  usually  found  upon  the  upper  molars.  Two  may 
exist  on  opposite  sides  of  a  molar,  as  in  a  specimen  possessed  by  the 
editor.    They  may  cause  neuralgia.     (Ottofy.) 

A  molar  root  may  have  a  cap  of  enamel  upon  its  apex,  an  evidence 
of  extreme  displacement,  even  more  than  shown  in  Fig.  178.    Some- 


180     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

times  an  enamel  ridge  runs  down  the  side  of  a  root;  sometimes  an 
excrescence  may  be  found  upon  the  enamel  (Fig.  176).     Fig.  175 

Fig.  179 


Structure  of  enamel  nodule.     E,  enamel;  D,  D,  dentin.     (Hopewell-Smith.) 

shows  enamel  formed   in   the  bifurcation  of  the  roots  of  a  lower 
molar.    The  enamel  nodule  has  been  explained  upon  the  hypothesis 


Fig.   180 


Fig.   181 


Fig.   182 


Upper  molar 
with  supplemental 
cusp  on  lingual 
side. 


Showing  talon-like  un- 
usual development  of 
the  cingule  on  an  incisor. 
(From  case  reported  by 
W.  H.  Mitchell,  Dental 
Cosmos,  vol.  xxxiv.) 


Very  large  supplemental  cusp 
on  the  buccal  surface  of  upper 
molar.  Probably  a  fused  "para- 
molar." 


that  the  remains  of  the  epithelial  root  sheath  of  Hertwig  have  within 
them  the  inherent  power  of  forming  enamel,  which  may  account 
for  enamel  on  the  side  or  end  of  a  root.    As  this  epithelial  root-sheath 


MACROSCOPIC  MALFORMATIONS 


181 


is  probably  the  trailing  remains  of  the  enamel  organ  left  as  the 
organ  is  carried  up  by  the  tooth,  it  is  quite  likely  that  larger  portions 
of  the  organ  may  be  detached  as  above  explained.     (See  Fig.  186.) 


Fig.  183 


Fig.  184 


Fig.   185 


Cuspids  with  long  roots. 


Curved  roots. 


Upper  cuspid  with  two  roots. 


Supplemental  Cusps. — Occasionally  a  tooth  has  a  greater  number  of 
cusps  than  usual.  The  most  common  form  of  this  condition  is  a 
supplemental  mass  attached  to  the  palatal  side  of  the  mesopalatine 


Fig.  186 


Developing  tooth  showing  Nasmyth's  membrane  over  enamel;  also,  Hertwig's  root 
sheath.     (Section  by  Addison.) 

cone  of  the  upper  first  molars  (Fig.  180).  Sabouraud^  claims  that 
this  is  a  sign  of  sj^hilis  even  when  occurring  as  the  only  stigma  in 
an  otherwise  perfect  set  of   teeth   and   claims   twenty  consecutive 


1  Dental  Cosmos,  1917,  pp.  759  and  1043. 


182     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

positive  Wassermanns  in  connection  with  it.  Mozer  and  Chenet 
found  but  one  such  cuspal  arrangement  among  sixty  children  known 
to  be  syphiHtic,  and  among  those  in  whom  no  taint  was  discoverable 
the  cusp  was  found  nineteen  times.    Twenty- three  men  examined  by 


Fig.   187 


Fig.  188 


Fig.  189 


Short  buccal  root  of  a 
molar,  otherwise  properly 
developed. 


Central  incisor  with 
short  root. 


Five-rooted  upper  third 
molar. 


Fig.   190 


Jeanselme^  having  this  cusp  gave  negative  Wassermann  tests.  It 
would  therefore  seem  not  pathognomonic  but  might  be  used  as  a 
point  of  suspicion  if  a  lesion  of  unknown  origin  exists  and  the 
patient  be  subjected  to  the  Wassermann  as  Sabouraud  has  claimed 
advantage  in  several  cases.  It  is  more  rarely  the 
case  that  a  cingule  of  this  sort  is  noted  upon  the 
lower  molars.  The  palatal  tubercle,  the  promi- 
nence upon  the  cingule  of  an  upper  incisor,  may 
be  of  exaggerated  size.  In  one  case  (Fig.  181) 
this  development  gave  the  appearance  of  a  talon 
upon  the  tooth,  a  distinct  cusp  segment  in  itself. 
Fig.  182  illustrates  a  marked  supplemental  cusp 
upon  the  buccal  surface  of  a  molar.  A  fusion  in 
this  location  is  not  impossible.  (See  Fourth 
Molar.) 

Malformations  of  Roots. — Differences  in  regard 

to  the  size,  arrangement,  form,  and  number  of 

the  roots  of  teeth  are  the  most  common  of  the 

dental  malformations.    The  roots  of  teeth  may  be 

abnormally  long  (Fig.   183)  or  abnormally  short 

(Figs.  187  and  188). 

The  roots  of  cuspids  may  be  bifurcated,  particularly  in  the  lower 

jaw  (Fig.  185).     A  central  may  have  a  short  supplemental  root. 

(Guilford^),  or  sometimes  two  distinct  roots  as  in  Fig.  190. 


Two-rooted  upper 
right  central  incisor 
(Warren. 2) 


1  Dental  Cosmos,  1918,  p.  447. 
'  American  System  of  Dentistry. 


2  Dental  Brief,  April,  1913. 


MACROSCOPIC  MALFORMATIONS 


1S3 


The  upper  first  bicuspids  may  have  trifurcated  roots,  the  extra  j-oot 
usually  being  on  the  buccal  aspect.  The  upper  second  bicuspid  may 
be  bifurcated;  upper  molars  may  have  more  than  three  roots,  the 


Fig.  191 


Fig.  192 


Fig.  193 


Two-rooted  lower  cuspid. 
Resorption  of  temporary 
roots.  (Radiograph  by  E. 
Ballard  Lodge.) 


Fibrous  odontome.  Results   of   hernia   of 

(Garretson,         after  pulp,     (Salter.) 

Pierce.) 


Fig.  194 


Fig.  193  magnified. 


184     MALFORMATIONS  AND  ANOMALIES  OF  THE   TEETH 

third  molar  often  having  four,  five,  or  six,  and  in  one  case  reported, 
eight  roots  (Figs.  178  and  189).  In  some  cases  upper  third  molars 
have  but  one  root  with  a  single,  large  canal,  a  case  of  true  develop- 
mental fusion  or,  so  to  speak,  original  intent  of  the  pulp  which  has 
not  divided  as  usual.  In  other  cases  the  roots  are  fused  so  as  to  form 
apparently  but  one  root,  while  the  canal  divisions  may  exist.  This 
may  be  fusion  or  concrescence  of  roots.  Lower  molars  may  have 
three  or  four  distinct  roots,  but  rarely  only  one. 

Abnormalities  of  root  form  are  of  extreme  frequency,  and  are 
probably  explained  upon  the  h^^pothesis  of  flexion  of  the  root  pulp, 
previous  to  the  deposition  of  the  curved  portion  of  root  tissue. 

It  is  impossible  to  diagnose  the  forms  of  roots  from  the  appear- 
ance of  the  crowns,  but  a  skiagraph  will  determine  their  form  with 
certainty.  It  may  be  said,  however,  that  narrow  necks  indicate  a 
probable  divergence  of  roots,  and  vice  versa. 

An  excrescence  upon  the  cementum  is  known  as  a  cemental  nodule. 

Fig.  195  Fig.  196 


Radicular  odontome.    (Tomes.)  Odontoma.     (Garretson.) 

Odontomata. — An  odontoma  is  a  growth  composed  of  structures  of 
which  the  teeth  are  composed,  but  the  masses  may  be  so  arranged 
as  to  have  no  typical  form  or  even  resemblance  to  a  tooth.  They  may 
appear  in  the  arch  or  may  remain  embedded  in  the  jaw,  where  they 
may  lie  quiescent  or  may  excite  cyst  formation  (Fig.  82,  page  187), 
or  give  rise  to  various  morbid  reactions,  such  as  tumor  formation. 

It  has  been  held  by  Broca  that  any  of  the  formative  organs  of  the 
tooth — enamel  organ,  dentinal  papilla,  or  follicle  wall — may  undergo 
aberrant  development  and  may  thereafter  deposit  calcific  tissue  or 
not,  as  the  case  may  be.  If  not,  soft  tumors  of  the  jaw,  not  dis- 
tinctly dental,  may  form,  though  in  its  complete  form  such  a  tumor 
may  become  a  seat  of  calcific  deposition  peculiar  to  the  aberrant 
tissue. 

Bland-Sutton's  classification  is  usually  adopted,  and  is  as  follows: 

1.  Aberrations  of  the  enamel  organ:  (a)  Epithelial  odontomes. 
(b)  Calcified  epithelial  odontomes. 


MACROSCOPIC  MALFORMATIONS  185 

2.  Aberrations  of  the  follicle:  (a)  Follicular  cysts.  (6)  Fibrous 
odontomes.    (c)  Cementomata.    {d)  Compound  follicular  odontomes. 

3.  Aberrations  of  the  papilla :  (a)  Radicular  odontomes.  (6)  Den- 
tomata.    (c)  Osteodentomata.     {d)  Cementomata. 

4.  Aberrations  of  the  whole  tooth  germ  (or  three  formative 
organs),  composite  odontomes. 

The  Uncalciiied  Odontomata:  1.  Epithelial  odontomata  which 
arise  by  aberrant  development  of  the  enamel  organ,  and  remaining 
uncalcified  resemble  the  adenomata. 

2.  Follicular  odontomata :  (a)  The  wall  of  the  follicle  is  distended 
and  the  cavity  is  filled  vdih  a  thick  fluid  (sometimes  pus  if  infected), 
and  contains  a  portion  of  imperfectly  developed  tooth.  It  is  in  this 
form  really  a  cyst  (Fig.  82).  It  is  probable  that  the  enlargement 
is  due  to  the  aberrant  development  of  epithelium  existing  in  the 
pericementiun  as  the  root  sheath  of  Hartwig  (pericemental  glands 
of  Black).  After  a  mass  is  formed,  degeneration  of  the  central  part 
into  a  liquid  forms  a  cavity,  lined  with  epithelium  and  contain- 
ing fluid.  The  cyst  formed  in  so-called  granuloma  at  the  end 
of  roots  containing  dead  pulps  may  come  under  the  classification  of 
follicular  cysts,  as  it  conforms  at  times  to  the  above  description  and 
the  pericementum  is  really  a  remains  of  the  follicle  wall.  (6)  The 
follicle  wall  or  pericementum  may  thicken  so  as  to  form  a  fibrous 
capsule  about  the  tooth,  sufiiciently  resistant  to  prevent  its  eruption 
(Fig.  192).     This  is  called  a  fibrous  odontome  and  is  considered  rare. 

3.  Compound  folHcular  odontomata:  The  follicle  wall  thickens 
into  a  fibrous  capsule,  and  in  this  may  appear  fragments  of  cemen- 
tum,  dentin,  or  imperfectly  formed  teeth  with  their  enamel,  dentin, 
and  cementum. 

It  is  a  combination  of  an  uncalcified  and  calcified  form,  and  might 
easily  lead  to  formation  of  a  cyst  containing  many  teeth  or  portions 
of  teeth  (a  dentigerous  cyst.  Fig.  82). 

The  Calcified  Odontomata:  1.  Epithehal.  The  enamel  organ 
develops  aberrantly  into  a  large,  possibly  multilocular  mass,  and 
enamel  deposition  occurs,  forming  a  large  mass  composed  of  enamel. 
The  enamel  nodule,  while  much  simpler  and  of  fairly  obvious  origin, 
is  now  classified  as  odontomatous. 

2.  The  Cementomata :  A  fibrous  odontome  forms  from  the  follicle 
wall,  then  calcifies  into  laminated  ossific  material.  One  from  a 
horse,  in  the  Royal  Veterinary  College,  London,  weighed  seventy 
ounces.    It  may  include  one  or  more  teeth. 

3.  Radicular  Odontomata:  The  crown  may  form  normally,  but 
the  dentinal  papilla  becomes  aberrant  and  develops  largely,  conveying 
with  it  the  follicle  wall.    Ceasing  to  enlarge,  cementum  and  dentin 


186     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

are  deposited  somewhat  in  the  ordinary  manner,  but  of  somewhat 
aberrant  deposition.  Pulp  hernia  comes  under  this  heading  and 
acts  similarly  (Figs.  193  and  195). 


Fig.   197 


Composite  odontome.     (Garretson.) 
Fig.   198 


Composite  odontome.     (Garretson.) 

4.  Composite  Odontomata:  The  developmental  organs,  the 
enamel  organ,  the  papilla,  and  follicle  wall  are  aberrant,  hetero- 
geneously  arranged,  enlarged,  and  then  deposit  a  composite  mass, 


MACROSCOPIC  MALFORMATIONS 


187 


which  may  be  somewhat  orderly  and  tooth-Hke  (Fig.  196),  or  be 
totally  unlike  a  tooth  as  in  Fig.  198.' 

The  diagnosis  of  odontoma,  if  at  all  obscure  may  be  made  by 
radiography  (Fig.  200). 

Treatment. — The  treatment  of  odontomata  is  usually  that  directed 
to  their  sequels,  which  consist  of  enlargements  about  the  jaws  with 
more  or  less  inflammation  or  cyst  formation,  and,  as  a  rule,  involves 
their  removal  by  surgical  operation. 

Fig.   199 


Structure  of  a  composite  odontome.     (Garretson.) 

Cysts. — A  cyst  is  an  enlargement  containing  a  cavity,  which, 
in  turn  contains  liquid,  gelatinous  or  pultaceous,  material,  about 
which  is  a  capsule  condensed  from  the  surrounding  structures. 
The  accumulation  of  the  fluid  or  semifluid  contents  produces  the 
enlargement  of  the  part  even  if  bonj^  (Fig.  82). 

They  differ  from  tumors  in  being  strictly  localized,  though  they 
may  be  large,  and  in  their  generally  benign  character,  though  tumors 
may  at  times  have  a  cystic  character. 

Cysts  may  be  formed  by  the  retention,  secretion,  or  extravasation 
of  fluid  in  several  ways:  (1)  By  the  retention  of  normal  secretion  of 
a  gland  owing  to  the  obstruction  of  its  duct — e.  g.,  ranula.  These 
are  called  retention  cysts.     (2)  By  abnormal  secretion  into  ductless 


1  The  classification  of  odontomata  by  Bland-Sutton  has  recently  been  modified 
by  the  British  Dental  Association,  but  does  not  seem  to  the  writer  to  offer  definite 
reason  for  substitutions.    For  a  synopsis,  see  Dental  Cosmos,  February,  1916,  p.  227. 


188     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

cavities — e.  g.,  bursse  (exudation  cysts).  (3)  By  the  extravasation 
of  blood  into  a  ductless  cavity  (extravasation  cyst).  (4)  Indepen- 
dently in  tissue  as  a  result  of  mucoid  or  fatty  changes  or  liquefaction 
necrosis,  the  surrounding  tissue  becoming  condensed  into  a  capsule 
(liquefaction  or  colliquation  cysts).  (5)  Independently  as  a  collection 
of  fluid  in  connective-tissue  spaces,  which  enlarge  and  fill.  The 
surrounding  tissue  condenses  into  a  cyst  wall.    (6)  Independently  as 

Fig.  200 


a  result  of  chronic  irritation  by 
foreign  bodies,  extra vasated  blood, 
or  parasites,  as  in  dentigerous 
cysts^  (Fig.  82).  Cysts  may  have 
but  one  cavity  (simple  cysts)   or 

Surgical  fracture  of    mandible,    with       have    numCFOUS    intcrcommunica- 
photograph    of    odontoma    and    molar         .  -x*      i  it/ 

tooth  after  removal.     (Graham.)  tmg  CaVltlCS  knOWU  aS  locull  (com- 

pound  or  multilocular  cysts). 
Forming  within  bony  walls,  these  may  be  largely  distended,  and  the 
walls  are  usually  thin.  There  is  generally  a  crackling  sound  produced 
upon  pressure.  Dentigerous  and  other  cysts  are  usually  lined  by  epithe- 
lium peculiar  to  the  part.  The  explanation  of  Malassez,  that  epithe- 
lial remnants  (of  the  enamel  organs)  develop,  forcing  the  connective- 

»  Green:  Pathology  and  Morbid  Anatomy. 


MACROSCOPIC  MALFORMATIONS 


189 


tissue  elements  outward  as  a  covering  to  them,  is  probably  the  correct 
one.  Meanwhile,  fatty  degeneration  of  developed  epithelium  and 
the  collection  of  fluid  account  for  the  fluid  or  pultaceous  character 
of  the  cyst  contents.  This  proliferation  of  epithelial  remnants  is 
well  proved  by  the  development  of  epithelial  products  in  the  interior 
of  dermoid  cysts.     (See  Fig.  203.) 

Fig.  201 


Longitudinal  section  of  a  tooth  from  an  ovarian  cyst:  a,  b,  d,  tissue  filling  absorp- 
tion cavities;  c,  narrow  band  of  connective  tissue  through  which  the  organ  a  received 
its  nourishment;   d,  absorption  of  enamel.     (Miller.) 

Dermoid  cysts  are  cystic  tumors  of  widely  varying  sizes  found  in 
various  parts,  such  as  the  ovary,  neck,  base  of  brain,  orbit,  etc. 
They  contain  fatty  and  epithelial  debris,  and  are  lined  with  epithe- 
lium, outside  of  which  is  a  corium  with  its  papillae,  and  outside  of 
this  subcutaneous  adipose  tissue.  The  whole  is  inclosed  in  a  fibrous 
capsule  of  connective  tissue.  The  epithelial  lining  may  contain 
and  develop  the  characteristically  dermoid  structures,  hair,  teeth, 
sebaceous  and  sweat  glands  (Fig.  203). 

BroomelP  states  that  the  hair  is  often  several  feet  long,  usually 
of  a  light  brown  color,  regardless  of  the  color  on  the  outside  of  the 


»  Dental  Cosmos,  X905. 


190     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

body,  and  becomes  white  as  age  whitens  the  outside  hair,  and  is 
usually  absent  in  dermoids  in  bald  persons.  Hair  follicles  are  present. 
He  states:  "Dermoids  of  the  mouth  are  usually  found  in  the  hard 
and  soft  palates,  infrequently  in  the  former,  but  when  found  are 
complicated,  while  the  more  frequently  found  in  the  soft  palate 
are  simpler.  In  these  situations  they  range  from  the  size  of  a  pea 
to  that  of  a  hen's  egg,  the  larger  being  pendulous.  They  are  also 
found  on  the  floor  of  the  mouth  and  dorsum  of  the  tongue.  Brown 
instances  a  case  in  which  one  lay  under  the  jaw  and  extended  down 
the  side  of  the  neck.'^  Blair-  states  that  when  not  found  in  such 
a  situation  they  occupy  a  position  beneath  the  skin  between  the 
geniohyoglossi  muscles. 

Fig.  202 


Absorption  tissue,  from  cavity  a  in  Fig.  201. 

"The  teeth  range  in  shape  from  the  simple  cone  to  multicusped 
complex  forms,  the  crowns  of  the  same  being  well  formed.  The 
roots  are  usually  not  fully  calcified  or  developed,  or,  perhaps,  partly 
developed.  A  follicular  wall  is  present.  The  enamel  may  be  smooth 
or  pitted. 

"The  cementum  is  usually  absent  or  but  slightly  developed. 

1  Dental  Cosmos,  1908. 

'  Surgery  and  Diseases  of  the  Mouth  and  Jaws, 


MACROSCOPIC  MALFORMATIONS 


191 


"Radicular  odontomes  evidenced  by  tumor-like  growths  on  roots 
are  due  to  aberration  of  the  dentinal  germ.  The  pulp  canal  was 
always  present  in  cases  examined.  Fusion  of  teeth  has  occurred  in 
these  cysts.  In  histology  the  teeth  are  similar  to  ordinary  teeth, 
with  some  slight  aberration  due  to  the  peculiar  condition." 

According  to  Eccles  and  Hopewell-Smith/  the  teeth  may  be  found 
imbedded  in  alveoli  in  bone;  that  a  small  jaw  with  normal-sized 
teeth  may  exist. 

Miller^  states  that  the  cystic  contents  include  fatty  acid,  oxalic 
acid,  large  quantities  of  tyrosin  and  leucin,  which  substances  furnish 
the  acid  for  the  decalcification  of  teeth  occasionally  found,  but  that 


Fig.  203 


ii^m    f 

V  f 

";> 

?! 

Portion  of  a  wall  of  an  ovarian  dermoid  cyst:  a,  wall  of  the  cyst;   b,  projecting  portion 
made  up  of  fatty  and  cutaneous  tissue;   c,  hairs;   d,  teeth.     (Ziegler.) 


no  bacterial  action,  such  as  occurs  in  the  second  stage  of  dental 
caries,  could  be  found.  He  stated  that  in  those  teeth  having  living 
pulps  transparency  might  be  found. 

Tumors. — A  tumor  is  a  swelling.  The  term  therefore  includes  all 
benign  enlargements  as  well.     Garretson  divided  them  into: 

1.  Those  having  an  explanation  m  local  conditions  which  are 
cured  upon  correction  by  surgical  means. 

2.  Those  unexplainable  upon  such  ground  (ordinarily  termed 
neoplasms).  These  are  due  to  abnormal  cell  growths  incited  by 
causes  not  clear,  cause  swelling  and  sap  vitality  and  if  of  malignant 

1  Proceedings  of  the  Royal  Society  of  Medicine. 

2  Dental  Cosmos,  1905, 


192     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

variety,  eventually  cause  death  by  toxemia  or  metastasis.  The 
consideration  of  tumors  belongs  to  "oral  surgery."  A  tumor  is 
obvious  and  if  not  of  the  first  class  should  be  referred  to  a  sm-geon 
for  diagnosis  and  treatment. 

Occasionally  a  benign  growth  arises  from  the  gum  which  fills 
with  blood  upon  circulatory  excitement  (epulo-erectile  tumor  analo- 
gous to  a  nevus)  or  a  small  growth  may  begin  about  a  tooth  socket. 
Sarcoma  which  if  not  apparently  due  to  conditions  about  the  teeth 
and  not  subsiding  as  an  inflammatory  tissue  should  be  referred  to  a 
surgeon  for  examination.  A  small  piece  may  be  taken  for  histo- 
logical examination.  Upon  the  hard  palate  or  along  the  jaws  a 
bony  protuberance,  otherwise  healthy  looking,  known  as  an  osteoma 
may  be  seen.  The  patient  occasionally  does  not  know  of  it.  It 
is  benign.  A  small  rounded  excrescence  is  occasionally  seen  upon 
the  cheek  or  lips.  It  seems  long-continued  and  benign  but  should  be 
referred  for  examination.  Ulcers  upon  the  tongue  should  be  considered 
in  the  light  of  syphilis  or  epithelioma.  A  small  papilloma  may  be  seen 
on  the  tongue.  Leukoplakia  frequently  seen  should  be  thought  of  in 
connection  with  syphilis  and  carcinoma.  (See  Index.)  Cases  of  grave 
tumors  of  the  jaws  are  frequently  seen  in  oral  clinics  which  are  the 
cullings  of  a  large  community  or  district.  They  are  rarely  seen  in 
dental  practice,  but  one  should  be  on  the  lookout  for  the  above  slight 
conditions  and  refer  them  to  oral  surgeons. 

Anomalies  of  Number. — Although  the  dental  series  of  man  nor- 
mally consists  of  thirty-two  members,  cases  are  frequently  observed 
in  which  the  number  is  less  than,  or  in  excess  of  that  number,  or  there 
is  an  abnormal  number  in  any  particular  group  of  teeth. 

Deficiency. — It  is  observed  with  some  frequency,  that  the  upper 
lateral  incisors  never  make  their  appearance,  a  condition  traceable  to 
the  influence  of  heredity  in  some  of  the  instances.  In  an  interesting 
case  of  three  sisters,  who  all  were  without  upper  laterals,  a  son  of  one 
of  them  had  them.  Unfortunately  the  history,  as  to  the  parents  of 
the  sisters,  was  not  certain,  as  they  wore  artificial  teeth. 

When  the  laterals  are  absent,  the  permanent  cuspid  erupts  and 
occupies  the  lateral  incisor  space,  and  thus  sometimes  fails  to  cause 
resorption  of  the  root  of  the  temporary  cuspid,  which  persists  in  the 
cuspid  space  (Fig.  52).  The  lower  laterals  sometimes,  but  more 
rarely,  fail  to  appear;  are  probably  never  formed  (Fig.  204).  The 
third  molar  mayj^never  appear,  or  appear  as  a  peg-like  tooth.  Usu- 
ally the  diminutive  tooth  is  in  the  upper  jaw  but  rarely  it  appears 
in  the  lower.  These  appearances  are  confirmed  by  reports  of  radiog- 
raphers.^ 

1  Johnson's  Operative  Dentistry. 


MACROSCOPIC  MALFORMATIONS 


193 


The  cuspid  often  is  impacted  but  is  seldom  lacking  in  formation. 
Usually  when  missing  it  is  to  be  found  by  radiography  but  may  be 
absent.  Kells  reports  such  a  case.  I  have  recently  had  a  lady 
patient,  sixty-four  years  of  age,  with  a  temporary  lateral  and 
cuspid  loosening.     Radiograph  shows  a  cuspid  descending. 

The  cases  of  suppressed  teeth,  next  in  point  of  frequency,  are 
those  of  the  bicuspid  teeth.  If  the  corresponding  teeth  are  all 
present  in  the  dental  arch,  a  well-founded  suspicion  of  impac- 
tion of  the  missing  tooth  may  be  entertained  and  a  radiograph 
resorted  to. 

Fig.  204 


Absence  of  both  upper  and  lower  laterals  in  the  same  mouth. 

cuspid. 


Temporary  left  upper 


An  excessive  growth  of  hair  upon  the  face  and  body  has  also  been 
associated,  in  some  cases,  with  a  deficiency  in  number  and  altera- 
tion in  form  of  the  teeth.  In  other  cases  no  abnormality  was  notice- 
able.^ In  some  cases  the  hair  and  other  dermal  structures  may  be 
normal  and  the  teeth  be  quite  deficient  in  number. 

The  extreme  of  suppressed  formation  is  represented  in  a  case 
described  by  Guilford. ^ 

A  patient  over  fifty  years  old  had  never  erupted  any  teeth,  tem- 
porary or  permanent;  the  alveolar  arches  revealed  no  evidences  of 
enclosed  teeth,  but  had  the  appearance  of  typical  edentulous  jaws; 
the  alveolar  bone  itself  was  but  primitive.  The  case  appeared  to  be 
sporadically  hereditary,  a  grandparent  and  an  uncle  exhibiting  a 


1  Tomes:  Dental  Surgery. 
13 


2  American  System  of  Dentistry,  vol.  iii. 


19-i     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

like  condition.  The  cases  are  interesting  also  because  of  additional 
evidences  of  faulty  evolution  of  dermoid  structures.  In  the  first 
case  cited,  no  sudoriparous  glands  appear  to  have  formed,  and  there 
was  but  a  faint  growth  of  hair  on  the  cranium,  and  none  on  the 
face  and  body.  The  uncle  was  hairless  and  edentulous  from  birth. 
Guilford  found,  in  other  members  of  the  family,  an  absence  of  the 
full  complement  of  teeth. 

Gibbs^  reports  two  brothers,  respectively  six  and  a  half  and  seven 
and  a  half,  as  without  teeth  or  sweat-glands.  It  appeared  to  be 
an  accentuation  of  atavistic  heredity  on  the  mother's  side. 

In  an  interesting  summary,  Kjaer^  quotes  Trueswell  as  knowing 
of  a  man,  aged  fifty-four  j^ears,  having  had  no  permanent  teeth,  but 
all  of  his  temporary  ones,  and  Fricke  as  having  3  cases  of  retention 
of  temporary  teeth  until  sixteen,  eighteen,  and  twenty  years  respec- 
tively, when  the  permanent  teeth  appeared,  and  Linderer  as  having 
a  case  of  a  lady,  aged  sixty  years,  who  never  had  any  teeth,  and  a 
case  of  his  own  in  which  the  temporary  teeth  were  lost  from  time  to 
time,  but  no  permanent  successors  appeared,  and  none  could  be 
detected  by  radiography.  He  attributed  the  lack  to  some  disturb- 
ance during  fetal  life,  as  the  family  history  did  not  include  such  a 
case. 

Excess. — The  possible  occurrence  of  a  condition  in  some  respects 
the  reverse  of  the  preceding,  has  been  much  written  of  and  discussed 
— i.  e.,  the  occurrence  of  a  complete  third  denture.  There  can  be  but 
one  conclusion  from  an  examination  of  all  the  evidence  thus  far 
presented,  and  that  is  that  no  clear  and  well-authenticated  cases  are 
made  out.  Isolated  cases  of  the  appearance  of  teeth  subsequent  to 
the  loss  of  all  of  the  second  denture  are  not  infrequent;  and,  so  far 
as  clear  records  can  be  obtained,  are  resolvable  into  cases  of  the 
eruption  of  supernumerary  or  impacted  teeth,  though  sometimes 
a  number  of  teeth  are  reported  erupted.  While  these  cases  are, 
at  least  for  the  present,  to  be  held  as  unproved  in  connection  with 
elderly  persons,  a  well-authenticated  case  of  multiple  dentition  in 
a  child  is  recorded  by  Catching.^  Between  the  sixth  and  seventh 
month  the  eruption  of  one  set  of  teeth  was  complete;  within  three 
months  all  of  these  had  been  lost.  Between  the  eleventh  and  fifteenth 
months  another  period  of  dentition  occurred,  the  teeth  of  this  second 
denture  being  of  such  faulty  structure  as  to  crumble  away  quickly. 
At  the  age  of  two  and  one-half  years  a  third  dentition  appeared, 
which  caused  the  child  such  inconvenience  that  the  teeth  were 

1  Dental  Cosmos,  March,  1916,  from  Dental  Record,  London,  November,  1915. 

«  Dental  Cosmos,  1907. 

3  Southern  Dental  Journal,  October,  1886. 


MACROSCOPIC  MALFORMATIONS 


195 


extracted  by  the  mother.  At  the  age  of  eleven  years  a  fourth  series 
erupted,  incomplete  through  the  absence  of  six  teeth.  At  the  age  of 
fifteen  years  these  teeth  were  sound  and  firm. 

The  Fourth  Molar. — A^ery  rarely  a  fully  developed  fourth  molar 
appears  in  the  maxilla.  In  one  case  it  was  impossible  to  distinguish 
the  normal.  The  third  and  fourth  lay  in  lingual  and  buccal  relation. 
Less  rarely,  a  less  typical  molar  appears  posterior  to  the  third  molar. 
This  must  be  very  rare  in  lower  molars.  A  third  type  of  super- 
numerary appears  in  the  maxilla.  These  are  rudimentary,  and 
appear  upon  the  buccal  side,  opposite  the  approximation  of  the 
first  and  second  molars  or  of  the  second  and  third  molars,  or  to  the 
distal  or  distolingual  of  the  third  molars.     Bolk^  calls  the  buccal 

Fig.  205 


The  fourth  molar.    In  situation  usually  occupied  by  a  paramolar.      (Hartnian.) 


supernumerary  the  "paramolars,"  and  says  they  are  small,  two- 
cusped,  single  rooted,  and,  if  fused,  usually  unite  with  the  mesio- 
buccal  portion  of  the  tooth  posterior  to  it  during  development.  Here 
it  forms  a  supplemental  section,  "paramolar  tubercle"  (Fig.  206), 
which  may  have  a  distinct  "paramolar  root"  or  root  indication.  Bolk 
accounts  for  the  less  frequent  appearance  of  an  anterior  independent 
paramolar  (opposite  the  approximation  of  the  first  and  second  molars) 
upon  the  supposition  of  a  more  frequent  fusion  with  the  second  molar, 
and  he  has  found  twice  as  many  "  paramolar  tubercles"  in  the  second 
molar  as  in  the  third.  The  supernumerary  posterior  of  the  third 
molar  he  terms  the  "distomolar,"  and  finds   that  when  fused,  it 

1  For  the  many  beautiful    illustrations    enforcing  this    conception    the    reader    is 
referred  to  the  article  in  Dental  Cosmos,  February,  1914. 


196     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

Fig.  206 


Paramolar  fused  to  third  molar. 
Fig.  207 


Paramolar  fused. 
Fig.  208 


Paramolar  fused  to  bicuspid. 
Fig.  209 


Fused  distomolar  in  the  mandible. 


MACROSCOPIC  MALFORMATIONS  197 

unites  with  the  distolingual  section  of  the  third  molar.  He  has  noted 
a  rare  case  having  both  a  paramolar  and  distomolar.  He  also  has 
not  observed  independent  paramolars  in  the  mandible,  but  the  para- 
molar tubercle  may  occur  on  the  second  or  third  molars,  which  may 
have  a  proper  "paramolar  root."  The  distomolar  in  the  mandible 
fuses  with  the  distolingual  portion  of  the  third  lower  molar.  He 
calls  attention  to  the  fact  that  in  the  maxilla,  the  paramolar  appears 
most  often  as  a  supernumerary  tubercle,  while  in  the  mandible  it  is 
emphasized  by  a  supernumerary  root. 

Fig.  210 


Two  atypical  upper  supernumerary  teeth  displacing  the  incisors. 

Bolk  regards  the  appearance  of  these  supernumerary  molars  as 
thus  subject  to  a  certain  degree  of  genetic  regularity.  The  fact 
that  one  of  the  -UTiter's  patients  had  a  free  paramolar  in  the  same 
location  on  both  sides,  both  alike  in  form,  shows  some  tendency  to 
type.  Xo  family  history  was  obtainable.  A  sister  two  years 
younger  has  none. 

In  several  cases,  however,  of  fused  para-  and  distomolars  the 
condition  has  been  unilateral. 

Supernumerary  Teeth. — Any  teeth  in  excess  of  the  normal  number 
of  teeth  belonging  to  any  one  class  are  included  in  the  category  of 
supernumerary  teeth.  The  number  of  teeth  may  possibly  not  exceed 
thirty-two.  Supernumerary  teeth  appear  as  simple  unmodified 
cones,  or  as  combinations  of  cones  resembling  the  forms  of  teeth. 
The  conical  form  is  most  common.    Cases  where  these  peg-like  teeth 


198     MALFORMATIONS  AND  ANOMALIES  OF  THE  TEETH 

appear  around  the  third  molars,  singly  or  in  number,  are  numerous. 
Their  appearance  in  any  situation  is  evidence  that  the  normal  number 
of  dental  cords  has  been  exceeded. 

Guilford^  divides  supernumerary  teeth  into  those  having  typical 
anatomical  forms  and  those  having  atypical  forms. 

Supernumerary  incisors  having  typical  forms  appear  in  either 
jaw.  In  the  upper  jaw,  supernumerary  centrals  and  laterals  both 
appear,  the  latter  more  frequently  (Fig.  171).  Supernumerary  teeth 
may  occupy  any  position  relative  to  the  dental  arch,  but  are  more 
frequently  seen  at  its  lingual  side.  The  compound  cone  occasionally 
appears  (Fig.  211).  In  addition  to  molars  and  incisors,  supernu- 
merary bicuspids  are  occasionally  found  (Fig.  79) ;  supernumerary 
cuspids  are  very  rare,  but  sometimes  a  brood  of  them  exists,  as  many 
as  seventeen  fairly  defined  small  teeth  having  been  removed  from  a 
cyst  in  the  location  of  the  cuspid  tooth.^ 

Fig.  211 


The  compound  cone. 

Unless  supernumerary  teeth  are  a  source  of  offence,  either  through 
their  position  or  appearance,  they  need  not  be  disturbed.  If  they 
are  found  to  be  so,  they  should  be  extracted.  In  the  case  of  a  patient 
having  had  five  supernumerary  teeth  descend  one  at  a  time  several 
years  apart,  the  last  (at  about  forty  years)  descended  labially, 
appearing  at  the  middle  thhd  of  the  right  central  root  against 
which  it  pressed,  forcing  the  central  lingually  so  as  to  also  force  the 
lower  central  and  lateral  inward.  The  force  of  erupting  teeth  is 
thus  shown. 

'  American  System  of  Dentistry,  vol.  iii. 

2  Bundy  Allen,  M.D.:    Jour.  Am.  Med.  Assn.     See  Dental  Cosmos,  1918,  p.  636. 


SECTION  IV. 

ACQUIRED  NON-SEPTIC  AFFECTIONS  OF  THE 
ENAMEL  AND  DENTIN. 


CHAPTER  VL 
ABRASION,  EROSION,  AND  MECHANICAL  INJURY. 

Formed  by  the  ameloblasts,  which  are  later  changed  into  Nasmyth's 
membrane,  and  borne  upward  with  the  crown  during  the  process 
of  eruption  (Fig.  186),  enamel  has  no  posteruptive  source  of 
nutritive  supply  from  without. 

Its  only  conjectural  source  of  nutrition  is,  therefore,  from  the 
pulp  via  the  dentinal  tubuli.  This  seems  to  have  been  proved  by 
Caush,  and  later  by  others.  (See  page  145.)  Teeth  do  change  in 
color  with  advancing  age,  generally  becoming  yellower;  this  is  prob- 
ably due  to  tubular  calcification  (which  see),  rendered  possible  by  the 
tubes  containing  organic  matter  which  are  now  supposed  to  permit 
a  slow  interchange  of  nutritive  sap.^  It  has  been  shown  by  Gies 
(see  page  145)  that  even  enamel  can  be  permeated  by  fluid.  This 
coloration  may  be  seen  in  cases  of  abrasion  and  in  some  cases  extends 
even  into  the  secondary  dentin  associated.  The  editor  has  a  patient 
with  a  vital  tooth  of  mahogany  brown  color,  which  she  claims  changes 
the  depth  of  color.  Changes  in  the  color  of  the  dentin  may  be  trans- 
mitted through  enamel,  which  is  normally  almost  or  even  quite 
transparent.  Such  a  transparency  may  be  seen  at  the  incisal  edges 
of  thin  incisors  before  these  edges  are  worn  down.  Another  proof 
of  transmission  of  color  through  enamel  is  seen  in  caries;  a  bluish- 
black  or  white  appearance  is  caused  by  the  decayed  ma  s  or  decalcified 
inner  surface  of  the  enamel. 

Again,  amalgam  or  gold,  oxyphosphate  or  oxychlorid,  reflects  its 
color  through  enamel,  and,  in  excavating,  the  shadow  of  the  excavator 
may  be  seen  through  thin  walls.  Enamel  may  be  stained  or  whitened 
by  decalcification  due  to  causes  acting  externally.    Extreme  polishing 

1  C.  Francis  Boedecker:  Dental  Cosmos,  September,  1911. 

(199) 


200     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

may  also  cause  a  new  character  of  light  reflection,  simulating  a  change 
in  color.  Talbot  claims  a  change  in  color  of  teeth  during  prolonged 
illness,  such  as  pneumonia,  typhoid  fever,  syphilis,  tuberculosis,  and 
in  pregnancy.^  With  advancing  age,  the  translucency  of  teeth 
verges  more  toward  transparency — apparently  a  sclerotic  change 
in  the  dentin.     (See  Transparency.) 

After  implantation,  a  tooth  may  somewhat  change  its  color,  but 
this  evidently  cannot  be  due  to  nutrition  from  the  pulp,  as  this 
organ  will  have  been  removed  before  implantation.  It  would  seem 
that  it  may  take  up  coloring  matter  from  the  saliva.  In  this  con- 
nection the  brownin  of  Black  should  have  consideration.  Its  appear- 
ance in  mottled  teeth  some  time  after  eruption  points  to  the  possibility 
of  infiltrations  from  without.     (See  page  157.) 

Enamel  may  suffer  mechanical  and  chemical  injury,  but  whether 
it  may  undergo  constructive  "changes  or  retrograde  metamorphosis 
is  at  present  only  conjectural.  There  is,  however,  a  possibility 
that  a  molecular  change  may  occur  as  a  result  of  slow  interchange 
of  fluid,  environment,  or  impact  of  mastication. 

The  dentin  and  cementum  contain  about  28  and  30  per  cent,  of 
organic  matter,  respectively,  and  stain  deeply  and  permanently  with 
great  readiness. 

Possessed  of  living  cells,  they  also  undergo  changes  in  their  structure 
under  the  influence  of  various  stimuli,  their  substance  being  added 
to  or  reduced  according  to  circumstances.  They  are  also  acted  upon 
by  mechanical  and  chemical  agencies,  if  exposed  to  their  influence. 

ABRASION. 

Abrasion  is  the  mechanical  wearing  away  of  tooth  substance. 

Occurrence. — It  occurs  most  commonly  upon  the  occlusal  surfaces 
of  teeth,  but  is  also  found  upon  the  approximal  and  labial  surfaces, 
the  labial  cervix,  and  more  rarely  upon  the  lingual  surfaces.  It  is 
also  seen  in  the  temporary  denture,  especially  in  the  molars,  and 
is  found  in  animals  (Figs.  224  and  225). 

Appearance. — Purely  abraded  surfaces  present  a  smooth,  flat,  or 
concaved,  highly  polished  appearance.  The  surface  may  become 
stained  or  otherwise  altered  in  color,  or  subsequent  caries  may 
remove  its  smooth  surface. 

Occlusal  Abrasion. — Occlusal  wear  is  very  common,  and  occurs 
largely  with  men  who  chew  tobacco;  the  contained  silex,  being  gritty, 
acts  as  an  abrasive.    Such  wear,  due  to  the  use  of  hard  food  or  gritty 

1  Dental  Cosmos,  1905,  p.  29. 


ABRASION  201 

substances,  is  seen  in  skulls  of  aboriginal  man.  Ottofy  describes  a 
peculiar  form  of  wasting  due  to  che^dng  betel  nut  mixed  with  bay 
leaves  and  slaked  lime.  No  doubt  a  gritty  element  is  introduced. 
An  example  of  wear  uncomplicated  by  any  other  possible  cause  is 
the  case  cited  by  Cottingham^  of  a  man  who  wore  down  two  sets 
of  artificial  teeth  "to  the  rubber  and  pins"  by  constantly  chewing  a 
variety  of  tobacco  said  to  be  usually  full  of  sand. 

Some  degree  of  occlusal  wear  is  accepted  as  normal  to  all  teeth,  the 
act  of  mastication  producing  marks  or  facets  at  the  point  of  articu- 
lation of  antagonizing  teeth.  A  tip-to-tip  variety  of  occlusion 
permits  free  lateral  movement  of  the  lower  jaw,  and  a  herbivorous 
type  of  articulation  causing  abrasion.  It  is  also  frequent  in  those 
cases  presenting  the  first  degree  of  prognathism.  In  some  of  these 
cases,  the  labial  surfaces  of  the  upper  incisors  and  cuspids,  and  the 
linguo-incisal  margins  of  the  lower  incisors  are  worn.  A  single  over- 
lapped lower  tooth  may  abrade  an  upper  tooth  in  this  manner. 

The  gritting  of  teeth  is  also  a  cause.  This  gritting,  termed  "bruxo- 
mania,"  may  occur  only  at  night  or  for  a  few  minutes  each  day; 
again  it  may  appear  for  entire  days,  weeks,  and  months,  not  ceasing 
even  during  sleep.  In  such  cases  the  teeth  are  worn  down  flat. 
Maria  and  Pietkiewdcz-  noted  12  cases  of  central  nervous  lesions, 
mostly  dementia,  developing  bruxomania;  also  it  has  been  noted  in 
cases  of  epilepsy  and  chorea.  A  similar  condition  is  the  nocturnal 
gritting  in  children  due  to  rectal  parasites  as  ascaris  lumbricoides, 
tenia,  etc.,  or  to  irritable  bladder  due  to  hj^peracidity  of  the  urine. 

A  clay  pipestem  may  wear  a  hole  of  its  own  diameter  in  the  incisal 
edges  of  anterior  teeth;  other  stems  wear  less.  Upholsterers  and 
seamstresses  have  peculiar  abrasions  (tack  holding,  thread  biting). 

The  undue  loss  of  posterior  occlusion  and  consequent  overuse  of 
the  anterior  teeth  cause  their  abrasion  after  the  manner  showm  in 
Fig.  212.  A  marked  overbite,  produced  in  any  manner,  may  cause 
lingual  abrasion  of  upper  anterior  teeth. 

Where  the  abrasion  occurs  in  a  fairly  regular  manner,  four  degrees 
of  abrasion  are  classified:  (1)  Abrasion  removing  the  cusps;  (2) 
abrasion  removing  the  occlusal  third  of  the  crown;  (3)  abrasion 
removing  the  middle  third  of  the  crowTi;  (4)  abrasion  extending  to 
the  gum  line  or  beyond.    (Broca.)     (See  Figs.  213  and  214.) 

When  there  is  a  marked  overbite  occlusion,  with  a  consequent 
lessening  of  the  lateral  movement  of  the  mandible,  the  teeth  do 
not  acquire  flattened  contact  surfaces,  but  their  cusps  increase  in 
sharpness  and  pointedness.    This  at  times  becomes  exaggerated,  and 

1  Dental  Digest,  September,  1917.  2  Dental  Cosmos,  1907,  p.  525. 


202      NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

Fig.  212 


Abrasion  of  anterior  teeth,  with  loss  of  posterior  occlusion.     (W.  A.  Capon.) 

Fig.  213 


The  first  and  second  degrees  of  abrasion.     Specimens  from  museum  of  Philadelphia 

Dental  College. 

Fig.  214 


The  third  and  fourth  degrees  of  abrasion.    Secondary  dentin  plainly  visible.    Specimens 
from  museum  of  Philadelphia  Dental  College. 


ABRASION  203 

produces  an  interlocking  of  cusps  or  rather  worn  surfaces  which 
have  very  sharp  edges. 

In  the  first  degree  of  abrasion,  the  dentin  is  often  hollowed  out  in 
advance  of  the  enamel  of  the  cusps,  forming  concave  places  in  which 
berry  seeds  lodge  and  cause  annoyance.  These  spots  are  at  times 
hypersensitive.  The  plane  surfaces  also  are  often  sensitive  upon 
merely  rubbing  the  teeth  together.  The  great  majority  of  worn 
surfaces  are  comparatively  insensitive.  Tobacco  stains  often  per- 
meate the  occlusal  dentin. 

Labial  Abrasions. — Some  forms  of  abrasion  have  been  attributed 
to  too  vigorous  use  of  tooth-brushes,  particularly  when  gritty 
powders  are  employed.  There  is  no  doubt  that  mechanical  abra- 
sion about  the  necks  of  teeth  is  produced  in  this  manner,  the  gum 
line  receding  beyond  the  enamel  border,  exposing  the  cementum; 

Fig.  215 


Abrasion  due  to  employment  for  twenty  years  of  a  gritty  English  tooth  paste. 
At  7,  gold  crown  abraded.    (Miller.) 

and  a  careful  examination  will  reveal  the  cementum  and  next  the 
underlying  dentin  to  be  affected;  the  enamel,  when  abraded,  shows 
first  as  a  facet,  then  as  a  spot  of  bare  dentin  with  thin  edges  of  enamel 
around  it  (see  the  left  lateral  in  Fig.  235),  and  later  the  area  may  be 
grooved.  As  a  rule,  however,  the  effect  shown  in  Fig.  234,  lower 
jaw,  is  the  more  common.  These  tooth-brush  abrasions  are  quite 
characteristic.  In  well-kept  dentures,  the  gums  are  seen  to  have 
receded  from  their  normal  line,  but  may  exhibit  little  evidences  of 
turgescence;  the  roots  of  the  teeth,  upper  and  lower,  are  exposed  to 
a  greater  or  less  extent  along  their  labial  and  buccal,  but  not  usually 
along  their  lingual  aspects;  and  they  are  excavated  to  variable 
depths,  upon  the  bicuspids  and  first  molars  more  than  upon  the 
other  teeth,  as  here  the  greatest  force  of  brushing  is  received.  The 
upper  cuspid  is  often  the  first  tooth  abraded.     The  depressions  have 


204     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

a  normal  dentin  color;  sometimes  deepened  in  the  mouths  of  non- 
smokers,  especially  when  brownish  secondary  dentin  is  deposited, 


Fig.  216 


A     B  c 


Abrasion  of  lingual  surface  by  assiduous  brushing  with  tooth  powder.     At  D  and  E 
amalgam  worn  down.   (Miller.) 

the  pulp  cavity  outline  often  being  evident,  and  which  in  smokers 
may  be  periodically  blackened  by  deposits  of  carbon.  If  caries 
supervene,  the  abraded  areas  lose  their  normal  color,  and  may  be 
readily  indented  by  sharp  instruments,  which  they  resist  before  the 


Fig.  217 


Fig.  218 


Labial  abrasion. 


Labial  and  lingual  abrasion. 


advent  of  caries.    The  bicuspids  and  molars,  particularly,  may  be 
grooved  in  such  manner  as  to  require  restoration  by  fillings. 


ABRASION 


205 


Miller^  investigated  this  subject  very  carefully,  and  found  that 
the  grit  in  many  forms  of  tooth  powder,  vigorously  used,  was  quite 
competent  to  wear  away  tooth  structure,  gold,  and  other  fillings 
(Fig.  219).  Figs.  216  and  218  show  a  lingual  wasting,  resembUng 
graphic  erosion.  In  both  cases  abrasion  is  proved  by  the  wasting 
of  metal,  which  acids  could  hardly  accomplish.  Crowns  and  fillings 
may  be  worn  out  occlusal ly,  especially  if  porcelain  occludes  with 
the  crowns  and  occasionally  worn  through  bucally  by  brushing. 
Miller  experimentally  proved  abrasion  competent  to  produce  the 
grooves  known  as  "wedge-shaped  defect"  (Fig.  220). 

Fig.  219 


Photomicrograph  of  sediment  obtained  by  washing  tooth  paste,  which   caused   the 
abrasion  shown  in  Fig.  215.    (Miller.) 


Calculus  may  be  worn  in  like  manner,  either  by  the  brush  or  by 
the  festoon  of  a  plate  (Fig.  223). 

I  have  had  a  case  of  notched  lingual  and  approximal  surface 
on  lower  incisor  cervices  due  to  abrasion  by  floss  silk  and  tooth 
powder  and  due  to  encircling  the  tooth  with  floss,  crossing  the 
ends  and  pulling  each  alternately.  This  was  done  by  my  direc- 
tion and  the  result  appeared  within  six  months.     While  the  effect 

1  Dental  Cosmos,  1907. 


206     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

was  on  the  cementum  and  dentin  the  cervix  at  the  gum  line  was 
not  cleansed  as  expected.  The  case  taken  without  consideration  of 
cause  could  have  been  mistaken  for  an  erosion. 

Fig.  220 


Artificial  abrasion  produced  by  brushing  with  a  much-used  English  tooth  paste  with 
motor  brush  for  eighteen  hours.    Remains  of  gold  filling  in  first  bicuspid.    (Miller.) 

Fig.  221 


Gradual  wear  of  both  tooth  substance  and  filling  material,  notwithstanding  the  open 

bite.     (Miller.) 


Miller  found  that  among  clinic  patients  who  never  used  a  tooth- 
brush the  labial  abrasion  was  wanting,  and  he  observed  that  a 


ABRASION  207 

cessation  of  wear  followed  the  abandonment  of  the  use  of  gritty 
powder  and  the  adoption  of  a  soft  brush  and  mild  powder,  which  is 
the  evident  indication  in  such  a  case. 

A  clasp  may  abrade  a  tooth,  and,  if  food  debris  be  retained  on  its 
inner  side,  caries  may  follow  in  the  abraded  area.  The  purely  abraded 
surface  will  be  polished. 

Approximal  Abrasion. — Slight  approximal  abrasion  may  be  normal 
as  a  facet,  due  to  the  rubbing  of  one  tooth  upon  another  at  the 
contact  point.  A  marked  example  of  this  was  seen  in  the  mandible 
of  a  skull  of  a  Maori.     (Museum  of  Philadelphia  Dental  College.) 

The  third  lower  molars  are  locked  beneath  the  distal  surface  of 
the  crowns  of  the  second  molars.  Some  form  of  bone  loss  occurred, 
producing  looseness  of  the  third  molars.  The  individual  motion  of 
the  teeth  produced  a  deep  abrasion  of  the  enamel  of  the  second 
molars  upon  the  distal  surface,  and  an  occlusoproximal  abrasion  of 
the  third  molars.     (Also  see  Fig.  278.) 

Extensive  approximal  abrasion  may  be  due  to  extrusive  elonga- 
tion of  a  tooth  in  one  or  both  jaws,  causing  a  tooth  to  occlude  with 
its  antagonist  with  a  glancing  motion. 

In  this  manner,  specimens  are  produced  abraded  from  the  occluso- 
approximal  angle  to  nearly  the  apex  of  the  root. 

Approximal  abrasion  by  shortening  the  mesiodistal  diameter 
causes  the  tooth  to  often  occupy  a  space  slightly  too  large  for  it 
This  leads  to  food  packing,  and  septal  gingivitis  or  to  non- septic 
pericementitis,  bone  resorption  and  looseness.  The  combined 
causes  together  with  the  use  of  tooth  picks  leads  to  a  form  of  peri- 
odontoclasia, often  classed  as  pyorrhea.  (The  ideas  are  fully  devel- 
oped under  the  heading  of  Non-septic  Pericementitis.) 

Grit  in  powder  may  easily  be  detected  by  taking  a  small  portion 
between  the  incisor  teeth,  or  may  be  found  by  elutriating  the 
powder,  i.  e.,  place  in  water,  stir,  let  settle  for  a  few  seconds,  pour 
off  the  supernatant  fluid,  and  examine  the  sediment  as  above,  or 
microscopically  (Fig.  219). 

Miller  found  from  experiments,  as  to  the  effects  of  various  acids 
acting  for  a  time  and  followed  by  brushing  with  abrasives,  that  it 
depends  very  materially  upon  the  nature  of  the  acid.  Those  acids 
which  rapidly  decalcify  (soften)  the  dentin,  of  which  we  may  take 
hydrochloric  and  lactic  as  t^'pes,  most  readily  retard  the  wearing 
away  by  friction  (unless  the  friction  be  so  great  as  to  wear  in  spite 
of  the  decalcification).  While  those  which  act  slowly  on  the  dentin 
(oxalic,  tartaric,  etc.),  as  well  as  those  which  have  a  macerating 
effect  on  decalcified  dentin,  may  be  wanting  in  this  influence.  He 
concluded  that  wear  could  not  be  produced  by  acid  alone,  but  that 


208     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 
Fig.  222  Fig.  223 


a,  abrasion  of  lingual  surfaces;  b,  of 
amalgam  filling  produced  by  a  plate. 
(Miller.) 


Abrasion  of  calculus.  (Miller  ) 


Fig.  224 


/'    €: 


f'l 


mi^ 


t  u 


■..■J 


Fig.  225 


.    -^ 


Abrasion  of  lower  incisors  of  a  horse     Defects   resembling  wasting   in    the  teeth 
produced  by  "cribbing."     (Miller,  after  of  a  sea  lion.    (Miller,  after  Murie.) 

Kitt.) 


ABRASION  209 

any  acid  or  acid  salt  which  possesses  the  power  of  extracting  the 
calcium  salts  from  enamel,  or  of  breaking  up  the  connection  between 
the  enamel  prisms,  may  accelerate  the  process  of  wasting,  provided 
the  necessary  mechanical  factor  works  together  with  it.  Miller 
found  food  to  be  a  negligible  quantity  as  to  wear  upon  labial  surfaces. 

The  editor  has  a  patient  presenting  the  general  characteristics  of 
Fig.  236,  who  has  been  a  brush  enthusiast,  and  was  taught  in  early 
life  to  use  a  toilet  soap  containing  fine  pumice  (Bazin's  poncine  soap). 

The  festoon  of  a  metal  plate  may  rapidly  cause  abrasion  of  the 
lingual  cervix  of  a  tooth.  The  condition  is,  however,  rare;  caries 
being  more  common.  In  the  editor's  practice  a  case  was  seen,  in 
which  several  teeth  were  so  affected  in  a  few  months,  by  an  ill-fitting 
metal  plate.  The  festoon  of  a  vulcanite  plate  has  also  produced 
such  an  abrasion. 

Abrasion  sometimes  follows  caries,  when  the  latter  has  become 
freely  exposed  to  attrition.  The  softened  surface  wears  away  and 
the  part  assumes  a  polished  appearance,  but  is  discolored  as  the 
result  of  the  stain  due  to  the  caries.  (See  Eburnation.)  Also 
caries  may  follow  abrasion  at  some  spot  which  later  escapes  the 
constant  wear. 

It  is  probable  that  a  hyperacid  condition  of  the  saliva  in  con- 
nection with  mechanical  forces  may  be  a  cause  of  rapid  abrasion. 
(See  Erosion.) 

Effects  of  Abrasion. — These  are  external  and  internal,  and  most 
marked  in  the  occlusal  variety.  The  crown  wears  down  until  at  times 
the  gum  is  reached.  In  the  process  sharp  edges  of  enamel  are  formed. 
These  splinter  off,  leaving  rough  edges,  or  the  enamel  may  fracture 
or  split  longitudinally,  following  the  axis  of  the  crown.  Supported 
by  dentin  it  does  not  further  break  away  (Fig.  242). 

Sharp  enamel  edges  may  irritate  the  tongue,  producing  ulcers  of  a 
sometimes  chronic  type,  which  acquire  indurated  edges  and  simu- 
late syphilitic  sores  or  epithelioma.  The  causal  relationship  between 
sharp  edges  of  the  teeth  and  lingual  epithelioma  appears  to  be  quite 
clear  in  some  cases.  Brown^  mentions  a  case  of  tetanic  spasms  of 
masticatory  muscles  due  to  this  source. 

Sores  which  have  given  evidence  of  malignancy  and  been  diag- 
nosed as  malignant  growths,  have  been  cured  by  rounding  and 
polishing  sharp  and  irritating  enamel  edges  of  teeth. 

The  continued  stimulation  of  the  ends  of  the  dentinal  fibrillse,  which 
are  exposed  in  abrasion,  causes  them  either  to  become  hypersensitive 
or  stimulates  them  to  formative  activity.    Tubule  material  is  built 

1  Dental  Cosmos,  1908,  p.  4. 
14 


210     XOX-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

upon  the  inner  walls  of  the  tubule,  obliterating  their  lumen.  This 
is  the  so-called  tubular  consolidation  or  calcification  (eburnation) . 
Accompanying  this,  secondary  dentin  is  often  formed.  As  a  result, 
most  commonly  the  pulp  chamber  of  the  crown  is  filled  up  with 
secondary  dentin  as  the  abrasion  proceeds,  and  the  crown  may  often 
be  worn  off  until  the  cervix  is  reached,  while  the  pulp  remains  vital 
and  covered  (Fig,  214).  In  some  cases  the  abrasion  closely  ap- 
proaches the  pulp,  which  has  failed  to  protect  itself,  probably  because 
of  atrophy  of  odontoblasts,  and  the  phenomena  of  hyperemia,  or 
even  exposure,  and  its  results  occur.  A  left  upper  bicuspid  of  the 
second  skull  in  Fig.  214  was  in  this  state. 

Grieves^  states  that  "abraded  teeth  are  also  affected  with 
cemental  h^^erplasia,"  which  may  either  be  due  to  mild  pulpal 
hj'peremia  extending  to  the  pericementum,  or  to  reflex  irritation,  or 
to  direct  production  of  mild  pericemental  hj^peremia  by  strong 
occlusion. 

Fig.  226 


Same  case  as  Fig.  212.     Bite  opened  by  bridge-work,  posteriorly.     Anterior  teeth 
restored  by  means  of  Land  jacket  crowns.     (W.  A.  Capon.) 


Treatment  of  Abrasion. — In  the  cases  of  cupped  occlusal  dentin, 
hard  fillings  of  platinum  gold  or  platinized  gold  inlays  are  best. 
Whether  the  filling  be  built  in  or  an  inlay  be  set,  it  is  advisable  not 
to  cut  too  closely  to  the  enamel  in  making  the  cavity,  for  the  struc- 
ture of  such  a  wall  is  often  fractured  after  filling  when  this  is  done. 
If  possible  the  form  in  Fig.  227,  with  retention  made  elsewhere  than 
near  the  side  enamel  is  preferable.  Inlays  requiring  only  pin 
anchorage  are  preferable  when  undercutting  would  weaken. 

If  nearly  all  teeth  are  present  and  the  abrasion  slight,  bridge-work 
may  be  used  to  restore  the  full  occlusion  without  attempt  at  restora- 
tion of  the  worn  surfaces.  When  all  teeth  are  present  any  causes 
should  be  stopped  if  possible  and  in  some  cases  nothing  further 
attempted, 

J  Dental  Cosmos,  1915,  p.  1125, 


ABRASION 


211 


Fig.  227 


If  the  abrasion  of  the  upper  anterior  teeth  be  deep,  the  bite  may 
be  raised  by  appropriate  posterior  crowms  or  bridges,  and  solid 
platinum-gold  fillings  may  be  built  upon  the  anterior  teeth,  either 
the  uppers  alone  or  upon  both  the  upper  and  lower  teeth.  Anchor- 
age may  be  obtained  in  the  dentin,  or  screws  ma}'  be  planted  in  the 
dentin  between  the  enamel  and  pulp  and  the  fillings  be  built  about 
them.  Instead  of  malleted  fillings,  tips  of  the  gold-inlay  type  may 
be  made  (Figs.  228  and  229).  Casting  the 
inlay  is  a  simpler  method.  Usually  it  is 
better  to  use  an  alloy  of  iridioplatinum 
gold.  This  applies  also  to  the  lingual 
occlusal  abrasion  of  incisors. 

For  those  cases  in  the  second  degree, 
as  a  means  of  limiting  the  abrasion.  Dr. 
J.  C.  Curry  has  introduced  small  trun- 
cated cones  of  unannealed  iridioplatinum, 
which  are  to  be  cemented  into  holes 
drilled  into  the  occlusal  faces  of  the  molars 

and  bicuspids  with  an  inlay  drill  of  exactly  corresponding  size, 
mounted  in  the  right-angle  hand  piece.  As  many  are  put  in  as 
the  safety  of  the  pulp  and  the  enamel  will  permit.  They  act  upon 
the  same  principle  as  steel  nails  in  a  shoe  heel. 


Manner  of  preparing  the 
outer  retaining  wall  of  a 
cavity  in  case  of  cupped  oc- 
clusal abrasion. 


Fig.  228 


Fro.  229 


Fig.  230 


Gold  tip  for  abraded 
teeth  with  living  pulps. 
(Evans.)  If  cast  the  mar- 
gins are  to  be  beveled  out- 
wardly. 


Gold  tip  for  abraded 
teeth  with  pulps  re- 
moved.   (Evans.) 


Porcelain-faced  crowns 
for  teeth  with  living  pulps. 
(Evans.) 


In  other  cases,  after  securing  a  proper  opening  of  the  bite  and 
posterior  occlusion  with  crowns  or  bridges,  single  porcelain-faced 
gold  or  platinum  crowns  may  be  made  to  cover  each  of  the  anterior 
teeth.  For  this  purpose  the  crown  is  appropriately  reduced  to 
convenient  form,  but  the  pulps  need  not  be  destroyed.     Fig.  230 


212     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

represents  the  method  outhned  by  Evans.^  There  can  be  no  objec- 
tion to  pulp  removal  in  any  of  these  cases,  if  for  any  reason  a  dowelled 
crown  seem  necessary  provided  careful  canal  filling  is  done.  (See 
this  and  Granuloma.) 

Land  jacket  crowns,  consisting  of  a  wedge-shaped  platinum  jacket, 
with  a  porcelain  facing  attached  by  means  of  one  of  the  numerous 
inlay  bodies,  may  be  used  instead  of  the  Evans  crown.  In  some  cases 
other  forms  of  crowns  may  be  indicated  (Fig.  226). 

In  raising  the  bite  or  for  cases  in  which  vital  teeth  cannot  be 
much  ground,  Dr.  EUwood  Garrett  has  suggested,  as  valuable  after 
long  experience,  the  use  of  a  crown  with  a  cusp  made  of  a  single 
thickness  24-gauge  clasp  metal  stamped  between  a  die  and  counter- 
die  of  zinc.     No  solder  filling  is  used. 

In  labial  abrasions  approaching  the  degree  shown  in  Fig.  236, 
screws  may  be  set  upon  either  side  of  the  pulp  and  silicate  cement 
built  to  the  original  labial  form.  Of  course  if  undercuts  are  per- 
missible and  sufficient  they  may  be  used. 

There  present  at  times,  cases  of  abrasion  in  which,  aside  from  the 
wear,  pyorrhetic  conditions  may  be  present,  or  where  bridges  cannot 
be  properly  inserted,  especially  when  only  a  few  teeth  remain. 

If  this  pertain  to  the  upper  jaw  only,  the  lower  denture  may  be 
restored  to  usefulness,  the  upper  teeth  extracted,  and  a  full  upper 
denture  inserted;  this  permits  the  adjustment  of  the  bite  to  any 
desired  level.  If  the  conservation  of  a  few  teeth  is  desirable,  they 
may  be  crowned  or  bridged;  the  occlusion  being  raised  if  desirable, 
then  a  plate  constructed.  If  the  condition  be  transferred  to  the 
lower  jaw  and  the  anterior  teeth  be  in  good  condition,  a  piece  with 
the  Roach^  or  Morgan  type  attachment  may  be  fixed  upon  cuspid 
or  bicuspid  crowns,  but  not  be  allowed  to  rock  with  the  attach- 
ment as  a  fulcrum. 

It  is  to  be  remembered  that  in  any  case  of  opening  of  the  bite,  the 
occlusion  is  to  be  restored  throughout. 

The  bite  must  not  be  raised  by  means  of  partial  plates  which  strike 
before  the  natural  or  crowned  teeth,  as  they  tend  to  embed  them- 
selves in  the  soft  tissues  and  create  inflammation. 

If  the  bite  be  only  slightly  raised  by  plates,  this  embedding  will 
cause  a  return  to  the  original  condition.  Sometimes  in  partial 
cases  the  natural  teeth  hold  the  occlusion  while  plates  unavoidably 
sink.  A  slight  allowance  may  properly  be  made  for  this.  Neither 
must  too  great  a  strain  be  placed  upon  supporting  teeth  (see  Over- 
work of  Teeth).     In  approximal  abrasion  the  indication  is  its  com- 

1  Crown  and  Bridge  Work.  '  Dental  Cosmos,  1908,  p.  17. 


ABRASION 


213 


pensation  by  tightening  the  contacts  by  fillings,  crowns,  etc.,  or  in 
some  cases  nnited  crowns  (splints)  are  necessary.    (See  Gingivitis.) 

In  case  of  hypersensitivity,  Robinson's  remedy,  silver  nitrate, 
nitric  acid,  or  the  actual  (hot  burnisher)  or  the  electrocautery  may 
be  effective;  if  not,  the  areas  should  be  excavated  and  filled,  or,  if 
necessar}^  the  pulp  should  be  devitalized. 

If  the  abrasion  be  caused  by  tobacco  or  gritty  powders,  etc.,  its 
use  should  be  stopped. 

A  difiScult  class  of  cases  to  treat  is  found  in  those  highly  nervous 
individuals  who  grit  their  teeth  during  sleep.  It  is  probable  and 
reasonable  that  this  cause  alone  may  serve  to  explain  abrasions  trace- 
able to  no  other  source.  The  cure  of  such  cases  as  these  could  only 
be  possible  through  the  wearing  at  night  of  some  modified  form  of 
interdental  splint.     Arnone  has  described  a  simple  vulcanite  splint 


Fig.  231 


Fig.  232 


The  "insulator."    (Arnone.) 


The  "  paraglossus. "  The  metal 
groove  shown  relates  to  another 
method  of  construction. 


for  the  lower  teeth,  to  open  the  molars  about  one-sixteenth  of  an 
inch  and  the  incisors  one-half  inch.  This  he  calls  "the  insulator," 
and  is  to  be  vulcanized  at  160°  C.  It  is  to  have  the  upper  surface 
rounded  (Fig.  231).  He  also  describes  "the  paraglossus,"  a  double 
vulcanite  splint  made  in  one  piece  to  be  inserted  by  bruxomaniacs 
during  sleep,  or  by  epileptics  during  the  forew^arning  "aura,"  if 
present,  to  prevent  grinding  or  tongue  biting.^  The  cases  naturally 
indicate  the  medicinal  use  of  a  bromide  before  retiring,  unless  the 
causes  can  be  discovered  and  removed. 

If  such  gritting  be  present  in  children,  the  evidences  of  irritable 
bladder,  due  to  hyperacidity  of  the  urine,  or  of  rectal  parasites,  should 
be  sought  and  treated.  The  urine  may  be  rendered  alkaline  by  the 
use  of  potassium  salts,  and  kept  so  by  restriction  to  a  largely  vegetable 


1  Dental  Cosmos,  1908,  p.  924, 


214     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

diet.  Belladonna  may  be  used  to  reduce  vesical  irritability.  Rectal 
parasites  may  be  removed  by  the  use  of  vermifuges,  or,  occasionally, 
by  rectal  injections.     (See  Medical  Works.) 

RESORPTION   OF   ENAMEL 

Definition. — Resorption  of  enamel  is  the  removal  of  enamel  sub- 
stance by  soft  tissue  containing  osteoclasts. 

Occurrence. — It    occurs    externally   only 
^i^-  233  [yi   impacted   teeth    surrounded,    at    least 

in  part,  by  irritated  tissue,  and  internally 
very  rarely  after  resorption  of  dentin  by 
the  pulpi  (Fig.  233).     (See  Pulpitis.) 

Such  tissue  may  also  be   found   in  der- 
moid cysts,  and   causes   the  resorption  of 
Impacted    cuspid    with     -teeth.     (See  Fig.  201.) 
resorption   of  enamel   and         Pathology  and  Moibid  AnatOHiy.— Ostco- 

a      hematogenic      calculus.  .  ,  , 

(Miller.)  clasts  approximate  the  enamel  as  they  ao 

cementum,  decalcify  and  resorb  it.  The 
dentin  is  next  attacked.  There  result  irregular  excavations  (How- 
ship's  lacunse)  and  white  or  discolored  areas  of  evident  slight  decal- 
cification of  the  enamel.  A  deposition  of  bone  into  the  area  may 
occur.^  The  process  is  probably  the  result  of  a  non-septic  inflam- 
mation, as  in  the  case  of  root  resorption.  (See  Interstitial  Gingivitis 
and  Resorption.) 

The  enamel  may  be  resorbed  from  its  internal  surface  after  the 
resorption  of  dentin  by  the  pulp  (see  Pulpitis),  and,  as  shown  by 
Woods,  may  be  filled  in  with  adventitious  material  of  a  structure 
resembling  cementum. 

Treatment. — Should  the  disease  by  chance  occur  upon  a  tooth 
which  later  has  come  or  been  drawn  into  place,  the  area  may  be 
filled;  otherwise  it  has  only  a  pathological  interest. 

EROSION. 

Definition. — Erosion  of  the  teeth  is  a  term  applied  to  the  chemical 
or  chemicomechanical  destruction  of  the  hard  tissues  of  the  teeth 
in  such  a  manner  that  broad,  shallow,  smooth  excavations  are 
made  in  the  enamel  and  dentin  in  situations  free  from  attrition 
by  mastication.^ 

>  Hopewell-Smith:  Histology  and  Pathohistology  of  the  Teeth.  "  Ibid. 

3  This  term  has  been  much  abused  and  applied  injiiscriminately  to  hypoplasias, 
caries,  abrasions  and  the  erosions.  It  seems  ad\dsable  to  restrict  it  to  the  above 
dental  definition. 


EROSION 


215 


Figs.  234,  235  and  236  illustrate  the  characteristic  appearance  of 
such  areas. 

The  demonstrations  of  Miller  with  reference  to  abrasion  of  labial 
and  lingual  surfaces  of  teeth  by  means  of  the  tooth-brush  and  gritty 
powders,  and  the  abrasion  of  approximal  surfaces  into  grooves  in 
animals  by  the  drawing  of  gritt}^  grasses,  etc.,  through  or  along  the 


Fig.  234 


Fig.  235 


Case  described  as  erosion.     (Darby.) 


Case  described  as  erosion    (Darby.) 


teeth,  or  the  gnawing  of  bones  by  carnivora,  etc.,  have  cast  a  heavy- 
cloud  of  doubt  upon  the  chemical  etiology  of  what  have  been  usually 
considered  as  erosions  due  to  the  action  of  acid  sodium  phosphate 
excreted  by  the  mucous  glands  of  the  lips  or  cheek. 


Fig.  236 


A  case  of  erosion  (drawn  from  the  cast) ;   B,  silhouette  from  a  perpendicular  line  through 
the  left  centrals,  upper  and  lower,  showing  the  loss  of  substance.   (Black.) 


The  appearance  illustrated  in  Fig.  234,  lower  jaw,  and  in  Figs. 
235  and  236  might  readily,  in  the  light  of  Miller's  demonstrations, 
be  regarded  as  abrasion,  if  the  causes  (brush  and  abrasive  powders) 
he  suggests  be  found;  but  the  graphic  outlines  shown  in  Fig.  234, 
upper  anterior  teeth,  seem  difficult  to  harmonize  with  the  abrasion 
theory.    The  cases  of  this  sort  are  rare  as  compared  with  the  others. 


216     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

the  editor  recalling  but  two  having  the  peculiar  undercut  mesial  and 
distal  erosion  borders.  The  spreading  of  brush  bristles,  as  the  brush 
is  brought  from  the  gum  down,  might  account  in  part  for  this,  but 
in  one  of  the  cases  mentioned  there  was  also  an  undercut  at  the 
incisal  border,  which  would  render  the  theory  difficult  of  application. 

One  case  was  in  a  man  aged  forty-five  years,  a  German  Jew. 
fond  of  wines,  beer,  etc.,  at  meals;  the  other  a  middle-aged  maiden 
lady  of  nervous  temperament,  with  whitening  hair,  slightly  wrinkled 
skin,  and  some  evidences  of  goutiness. 

Black^  mentions  approximal  erosions  of  peculiar  type.  This  is 
very  rare  at  least  with  me.  As  stated  on  page  205  I  had  a  case  of 
abrasion  due  to  flossing  with  use  of  chalk  which  looked  like  Black's 
approximal  erosion. 

According  to  Miller,  acids  or  acid  salts,  which  can  extract  calcium 
salts,  may  accelerate  the  wasting  process  provided  the  necessary 
mechanical  factor  works  with  it  and  wears  off  the  decalcified  tissue 
before  it  becomes  leathery,  when  wear  is  retarded.  Kirk  burnt 
asbestos  cloth,  treated  it  with  hydrochloric  acid,  neutralized  this 
with  ammonia,  washed  it  with  distilled  water,  and  again  subjected  it 
to  high  muflie  heat.  This  absorbent,  inorganic  cloth  he  applied  to 
buccal  glands  for  twenty  or  thirty  minutes  in  cases  of  erosion,  dis- 
solved the  mucus  obtained  in  distilled  water,  dialyzed  the  salts  out, 
and  examined  the  evaporated  residue  under  the  microscope  and  by 
reagents.  He  found  acid  sodium  phosphate  to  be  the  decalcifying 
agent  in  what  he  called  graphic  (hydroglyphic)  erosions  (Figs.  234 
and  235). 

Head-  found  by  experiment  with  a  1  to  20,000  solution  of  acid 
sodium  phosphate  in  water,  acting  in  the  incubator  at  body  temper- 
ature, that  superficial  decalcification  of  enamel  occurred  after  four- 
teen hours,  and  when  polished  off  it  again  decalcified  in  eight  hours, 
and  was  quite  superficially  decalcified  in  two  days;  that  a  5  per  cent., 
2  per  cent.,  1  per  cent.,  and  1  to  500  solution  acted  under  similar 
conditions  in  seventeen  hours,  and  points  out  that  a  solution  of  1 
to  10,000  and  1  to  20,000  acid  sodium  phosphate  in  alkaline  saliva 
acted  after  eight  and  five  days  only.  He  also  has  shown  that  enamel 
which  was  experimentally  slightly  decalcified,  again  hardened  when 
placed  in  saliva  for  a  time.  He  was,  however,  unable  to  explain  the 
result.^ 

Miller  found  the  slowly  acting  acids  do  not  produce  such  decalci- 
fication as  to  retard  the  abrasive  action  of  brushing  with  a  10  per 

1  Operative  Dentistry,  vol.  i.  2  Dental  Cosmos,  1907. 

3  Ibid.,  1910,  and  other  interesting  facts  pointing  to  the  same  conclusions  in  his 
text-book  Modern  Dentistry. 


EROSION  217 

cent,  pumice.  Given,  then,  a  decided  production  of  acid  sodium 
phosphate  by  the  buccal  glands  in  contact  with  the  labial  surfaces 
of  teeth  (Kirk)  for  eight  hours  (the  period  of  sleeping,  and  Head's 
period  of  one  experiment,  see  above),  it  is  quite  reasonable  to  suppose 
that  an  undetermined  percentage  of  acid  sodium  phosphate  dissolved 
in  buccal  mucus,  which  in  total  has  an  acid  reaction  to  litmus  (Tru- 
man, Kirk,  and  others),  is  competent  to  produce  a  superficial  decal- 
cification, which  the  morning  brushing  will  remove.  This  repeated 
for  months  or  years  may  produce  the  effect  seen.  Brubaker,  in  1894, 
immersed  a  tooth  for  a  week  in  a  solution  of  acid  sodium  phosphate, 
subjecting  it  daily  to  tooth-brush  friction,  and  at  the  end  of  that 
time  spots  and  grooves  resembling  erosion  made  their  appearance. 

According  to  Head  and  Kirk,  the  acid  phosphate  does  not  attack 
the  enamel  so  as  to  roughen  it,  but  leaves  it  translucently  smooth  and 
white,  and  this  mildness  of  the  action  of  the  acid  sodium  phosphate 
is  just  the  action  that  would  make  smooth  erosion  with  a  minimum 
of  abrasion.     (See  Miller's  experiments,  p.  207.) 

Head  points  out  "that  1  to  500  lactic  acid  in  water  will  decalcify 
enamel  in  thirty  minutes,  while  the  same  percentage  in  saliva'  does 
not  do  so  in  fifteen  days,  but  that  the  inhibitory  effect  of  saliva  is 
overcome  when  the  lactic  acid  has  a  strength  of  1  per  cent."  The 
inhibitory  effect,  therefore,  seems  to  lie  in  the  relative  relations  of 
the  acid  and  alkaline  element,  though  Head  has  shown  that  a  mix- 
ture of  1  per  cent,  solution  of  acid  sodium  phosphate  with  a  1  per 
cent,  solution  of  tribasic  sodium  phosphate,  which  is  capable  of 
turning  blue  litmus  red,  but  not  of  turning  red  litmus  blue,  placed 
the  acid  under  control  so  that  the  mixed  solution  did  not  corrode 
the  tooth  placed  in  it,  which  a  1  per  cent,  solution  of  acid  sodium 
phosphate  in  water  would  do. 

Regarding  the  production  of  the  abnormal  exudate  from  the  labial 
glands.  Kirk  argues  that  in  diseases  of  suboxidation  (resulting  in 
hyperacid  conditions  such  as  gout  and  rheumatism)  the  blood  is 
loaded  with  carbonic  acid  as  a  result  of  faulty  metabolism.  In  the 
epithelium  of  the  kidneys,  the  mass  action  of  the  carbonic  acid  upon 
the  sodium  phosphate  of  the  blood,  normally  produces  acid  sodium 
phosphate,  which  is  eliminated  in  the  urine,  and  sodium  bicar- 
bonate, which  is  returned  to  the  blood  and  maintains  its  alkalinity 
according  to  the  following  reaction:  HNa2P04+H2C03  =  H2NaP04 
-f  HNaCOs.  If  the  amount  of  carbonic  acid  be  of  only  normal  pro- 
duction, this  action  will  result  in  only  a  normal  amount  of  acid 
sodium  phosphate  in  the  urine  and  perspiration;  but  if  in  excess  and 
not  cared  for  by  the  lungs,  skin,  and  kidneys,  the  buccal  glands 
may  also  take  up  the  action  and  excrete  acid  sodium  phosphate 


218     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

in  an  identically  similar  manner.  The  acid  calcium  phosphate  is 
also  found  in  the  saliva  at  times,  and  can  be  formed  in  a  similar  way, 
the  calcium  phosphate  being  substituted  for  sodium  phosphate  as 
the  basic  salt. 

Kirk  states  that  in  the  saliva  of  arthritics  there  are  frequently 
found  acid  salts,  such  as  acid  sodium  phosphate  and  acid  calcium 
phosphate.  The  excessive  amount  of  carbonic  acid  accounts  for  the 
excessive  loss  of  phosphate  in  the  kidneys  seen  in  arthritics,  as  the 
acid  sodium  phosphate  and  acid  calcium  phosphate  require  for  their 
production  the  basic  phosphates,  and  the  elimination  of  those,  con- 
tinuously, produces  a  phosphaturia  until  depletion  of  phosphates 
occur,  when  their  amount  lessens  and  other  salts  appear. 

In  a  paper  published  in  1902,  Kirk^  describes  polariscopic  obser- 
vations made  upon  saliva  from  a  patient  afflicted  with  a  general 
erosive  wasting  of  the  teeth.  The  patient  had  had  attacks  of  in- 
flammatory rheumatism,  and  suffered  from  obstinate  constipation, 
periodic  attacks  of  migraine,  headaches,  and  neuralgia,  and  his 
saliva  was  most  acid  at  night.  The  saliva  was  dialyzed,  the  dialysate 
concentrated,  and  found  to  contain  lactic  acid  salts,  calcium  lacto- 
phosphate,  calcium  lactate,  and  magnesium  lactophosphate  (Fig.  237). 

In  view  of  these  two  classes  of  cases,  Kirk  has  suggested  that 
erosion  cases  may  be  of  two  kinds:  (1)  A  general  erosion,  in  which 
all  of  the  surfaces  are  uniformly  involved,  and  in  which  lactic  acid  is 
the  solvent  agent;  and  (2)  cases  distinctly  due  to  an  exudate  from 
abnormal  buccal  glands  or  gland,  the  acidity  of  which  is  due  to  either 
acid  sodium  phosphate  or  acid  calcium  phosphate.  Talbot^  claims 
that  the  systemic  acidosis  produced  by  various  diseases  and  by  fruit 
eating  in  excess  is  responsible  for  the  acidity  of  the  buccal  mucus 
and  saliva,  and  for  pulp  and  gingival  degeneration  and  resorption 
through  a  process  of  artery  and  nerve-end  degeneration.  A  decrease 
in  the  normal  acidity  of  the  urine  (below^  30)  indicates  renal  insuffi- 
ciency, and  the  difference  indicates  the  amount  retained  in  the 
system.  An  excessive  acidity  of  the  urine  indicates  excessively 
imperfect  oxidation.  This  expression  of  the  cause  is  quite  compatible 
with  the  view  of  Kirk,  and  both  are  views  of  general  malnutrition. 

The  disease  appears  to  affect  females  more  than  males;  appears 
usually  after  thirty  years  of  age,  and  often  some  history  of  goutiness, 
arthritis,  or  rheumatism  can  be  obtained.  JNIiller  denied  the  presence 
of  this  disease  in  the  gouty,  but  since  his  observation  the  \\Titer 
has  had  several  patients  hold  up  gouty  fingers  when  questioned  as 
to  a  possible  gout  as  a  cause  of  the  erosions  present. 

1  Items  of  Interest.  "  Dental  Cosmos,  December,  1907. 


Erosion 


m 


There  are  other  theories  which  do  not  seem  to  be  tenable.  In 
many  cases  that  have  progressed  to  a  marked  degree  the  process 
seems  to  have  ceased  spontaneously. 


Fig.  237 


Crystallization  of  salts  from  dialysate  of  saliva  from  erosion  case,  showing  two  tj-pieal 
forms.     Large  crystal  is  calcium  lactate.     (Kirk.) 


Fig.  238 


1 

1 

1 

^ 

1 

H 

^^M 

1 

ajs 

■^'^J^ 

i 

i 

•^^^^^^^^^B 

^^Bvi^ 

^H 

1 

H 

^S|'  % 

1 

^^l^^l 

^^^K,. 

m 

■ 

P 

xy    J 

1 

K^^^H 

^Hk^^V^ 

1 

1 

1 

1^ 

91 

Another  field  from  the  same  specimen  as  Fig.  237,  also  showing  two  tj-pal  forms. 
Large  crystal  is  calcium  lactate.    (Kirk.) 


220     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

Erosion  Due  to  Extraneous  Acids. — Miller^  describes  a  case  re- 
ported by  Davenport,-  of  Paris,  of  a  healthy  man  whose  teeth  were 
eroded  and  worn  away  by  acid  vap.ors,  within  six  months  of  entering 
a  factory  devoted  to  the  manufacture  of  nitric  and  sulphuric  acids. 
This  effect  was  observed  upon  the  other  workmen  also,  and  also  in 
workmen  in  a  dynamite  factory  in  which  these  acids  are  used.  The 
teeth  were  first  set  on  edge.  Miller  suspended  a  tooth  in  a  flask  con- 
taining equal  parts  of  nitric  and  sulphuric  acid,  and  found  that  the 
vapors  attacked  not  only  the  inorganic  but  the  organic  portion  as 
well,  so  that  upon  slight  rubbing  with  a  soft  tooth-brush  the  tissue 
was  worn  away,  leaving  a  hard,  polished  surface.    Miller  states  that 

Fig.  239 


Crystallization  from  solution  of  a  tooth  in  1  per  cent,  lactic  acid, 
calcium  lactate.     (Kirk.) 


Large  crystal  is 


the  vapor  is  nitrogen  peroxid,  N2O4.  Lemon  juice,  even  in  lemonade, 
and  vinegar  will  produce  this  effect  of  setting  on  edge,  which  undoubt- 
edly is  due  to  the  chemical  solution  of  a  small  portion  of  the  enamel, 
probably  the  interprismatic  cement  substance,  leaving  the  enamel 
globules  a  trifle  higher,  this  soon  being  worn  off  to  a  general  level 
again. 

Guilford^  mentions  a  case  of  erosion  caused  by  shaddock  (grape 
fruit)  eating.  Tomes  cites  cases  of  erosion  caused  by  lemon  and 
grape  sucking.    The  pitting  of  grapes  has  produced  cases  of  peculiar 


»  Dental  Cosmos   1907. 
3  Lectures. 


'  Transactions  American  Dental  Association,  1881. 


EROSION  221 

erosion  of  the  labial  and  lingual  surfaces  and  incisal  edges  of  anterior 
teeth.  In  one  case  in  my  practice,  the  incisal  anchorage  of  an 
approximal  gold  filling  was  almost  worn  away  upon  the  tooth  most 
used  to  pit  the  grape.  Unquestionably,  other  fruit  juices  or  acids 
might  act  in  a  similar  manner  if  the  acid  has  an  affinity  for  tooth 
structure,  and  the  exposure  to  its  action  is  sufficiently  lengthy  and 
often  enough  repeated  to  produce  effects. 

The  Effects  of  Erosion. — Tubular  calcification  and  secondary  dentin 
are  produced  together  with  atrophic  changes  in  the  pulp,  due  to 
secondary  dentin  formation.  Gold  and  amalgam  fillings  are  left  as 
raised  islands  by  the  wasting  of  the  tooth  around  them,  though 
Miller  has  shown  that  associated  abrasions  may  cause  their  wear, 
which  acids  evidently  can  hardly  be  expected  to  do. 

Scratches  shown  as  lines  and  Baume's  clefts  are  explainable  upon 
the  theory  of  abrasion  by  brush  and  powders;  though  usually  trans- 
verse, there  are  sometimes  vertical  lines.  The  stimulation  of  the 
dentinal  fibrillse  by  acid  or  mechanical  stimuli  may  cause  great  hyper- 
sensitivity; as  a  rule,  however,  this  is  not  pronounced  (Fig.  240). 

The  anterior  teeth  are  sometimes  shortened  so  that  their  occlusion 
is  lost.  Kirk's  lactic  acid  case  was  of  this  order.  The  carious  process 
may  become  implanted  upon  an  eroded  area,  or  at  some  part  of  it, 
usually  the  cervical  portion.  Whether  this  is  initiated  by  a  decal- 
cifying process  due  to  the  acid  sodium  phosphate,  or  uncleanliness 
due  to  a  cessation  in  the  intensity  of  the  brushing  or  due  to  imperfect 
brushing  at  this  point  as  is  common  in  most  teeth,  is  not  so  clear  as 
it  formerly  seemed,  when  it  was  thought  due  to  a  temporary  cessation 
in  production  of  acid  sodium  phosphate,  which  was  regarded  as 
immunizing  the  part  to  caries.  In  any  event  the  stain  of  iodin  is 
taken,  showing  the  presence  of  bacterial  films  at  the  point  showing 
caries. 

Diagnosis. — The  presence  of  the  peculiar  excavations,  the  hyper- 
sensitivity of  dentin  if  any,  and  the  acid  character  of  the  mucus 
from  the  follicles,  as  shown  upon  test  with  litmus  paper  made  just 
after  rising,^  are  diagnostic  signs  in  cases  of  acid  buccal  mucus. 
Kirk's  method  of  obtaining  the  acid  may  be  used.  (See  p.  216.) 
The  acid  reaction  is  not  marked  during  the  day.  The  writer  would 
suggest  that  on  rising  the  mouth  be  neutralized  with  sodium  bicar- 
bonate and  then  washed  with  water.  The  patient  is  then  to  apply 
the  litmus  with  clean  fingers  to  the  glands  for  ten  minutes  and 
preserve  the  litmus  for  examination.  This  will  give  the  acidity  of 
buccal  mucus  if  present.     If  found,  disease  of  suboxidition  may  be 

'  Truman. 


222     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

suspected  and  a  urinalysis  made  for  confirmation  of  the  general 
s\Tnptoms.  If  not  found,  habits  of  fruit  use,  occupation,  etc.,  may 
be  looked  for  or  looked  into  as  a  first  suspicion. 


FiQ.  240 


-EC 


Sagittal  action  of  human  incisor  prepared  by  Hopewell-Smith's  process,  and  stained 
with  hematoxylin:  E  C,  erosion  cavity,  on  surface  of  which  can  be  seen  Baume's 
clefts;  P,  pulp  tissue  undergoing  degenerative  changes;  F  C,  atrophic  odontoblasts: 
S  D,  secondary  dentin.      X  45.      (Hopewell-Smith.) 

Thirdly,  general  acidity  of  the  saliva  on  rising  or  during  the  day 
may  be  determined  by  test  repeated  by  the  patient. 


EROSION  223 

Fourthly,  sialo-analysis  as  given  by  Kirk  may  be  resorted  to. 

Failing  in  these  to  determine  acid  as  a  cause,  the  case  may  be 
considered  one  of  pure  abrasion,  especially  if  gritty  powders,  etc., 
are  used. 

Treatment. — The  treatment  of  a  true  erosion  if  diagnosed  as  above 
divides  itself  under  two  heads:  Prophylactic  and  restorative;  the 
prophylactic  is  again  divided  into  local  and  general  treatment.  The 
problem  of  eradicating  the  cause  of  the  disorder  lies  in  a  correction  of 
the  morbid  glandular  secretion.  It  is  evident  that  if  the  irritation 
and  altered  secretion  of  these  glands  be  due  to  some  systemic  cause 
a  disease  of  suboxidation,  notably  an  affection  of  the  gout  order,  a 
cure  of  the  local  disturbance  involves  the  cure  of  the  underlying 
systemic  cause.  Talbot^  reduces  the  acidity  to  normal  with  sodium 
bicarbonate  (10  to  30  grains),  or  sodium  chlorid  (45  grains),  after 
meals;  or  sodium  phosphate  morning  and  evening.  One-tenth 
grain  of  calomel  is  given  each  two  hours,  for  a  time,  to  cleanse  the 
bowel  and  stimulate  the  liver.  Eight  to  ten  glasses  of  water  should 
be  taken  daily.  A  practically  antigout  diet  and  hygiene  are  suggested 
to  increase  oxidation  and  elimination. 

Kirk,2  working  to  the  end  of  reducing  acid  buccal  secretion,  uses, 
three  times  a  day,  ^wo  grain  pure  phosphorus  in  olive  oil,  in  gelatin 
capsules,  along  with  a  very  mild  laxative,  and  when  the  urine  shows 
a  deficiency  of  phosphates,  25  to  30  grains  per  diem  of  glycerophos- 
phate of  lime  and  soda  are  given. 

Next  in  importance  to  the  prevention  of  acid  formation  is  its 
neutralization.  This  implies  the  application  of  alkalies  or  the  use 
of  alkaline  mouth  washes.  The  greatest  production  of  acid  occurring ' 
during  the  night,  applications  of  adhesive  masses  of  alkaline  sub- 
stances are  made  to  the  teeth  at  night.  The  principal  of  these  is 
prepared  chalk,  calcium  carbonate;  it  is  rubbed  over  the  labial  faces 
of  the  teeth  and  between  them,  before  retiring.  It  remains  in 
sufficient  amount  to  neutralize  any  acid  substances  coming  in  contact 
with  it. 

Excellent  results,  as  to  the  checking  of  the  progress  of  the  decal- 
cification, are  obtained  from  the  use  of  magnesium  hydrate  held  in 
suspension  in  water,  or  milk  of  magnesia.  Kirk  found  that  three 
hours  after  the  use  of  a  teaspoonful  of  the  milk  of  magnesia,  the 
saliva  maintained  an  alkaline  reaction.  It  should  be  used  at  night 
as  a  wash,  after  cleansing  the  teeth,  the  residue  to  be  left  as  an 
alkaline  coating  upon  the  teeth.  The  chalk  and  milk  of  magnesia 
may  be  mixed  into  a  paste.      If  the  preparation  be  disagreeable,  a 

1  Dental  Cosmos,  December,  1907.  ^  Dental  Cosmos,  1908,  p.  811. 


224     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

few  drops  of  essential  oil  may  be  added.  (See  Caries.)  The  induce- 
ment of  a  flow  of  alkaline  saline  by  the  use  of  acid  fruits  at  the  end 
of  a  meal  may  be  an  aid.  The  idea  is  elaborated  under  the  subject 
of  dental  caries  (see  Index).  The  abrasive  factor  and  its  possibilities 
as  causes  of  apparent  erosions  suggest  the  avoidance  of  any  strongly 
abrasive  powders,  or,  perhaps,  a  confinement  to  the  use  of  castile 
soap,  Bazin's  carbolic  acid  soap  and  a  soft  brush.  The  hypersen- 
sitivity, if  any,  is  largely  controlled  by  those  means  though  potas- 
sium carbonate  in  glycerin,  tannin  in  glycerin  or  Robinson's  remedy 
may  be  used.     (See  Hypersensitivity  of  Dentin.) 

It  has  been  suggested  by  Ottolengui^  that  in  the  earlier  stages  an 
impression  and  plaster  model  of  the  teeth  be  made  for  comparison 
at  future  dates,  so  that  the  progress  of  the  erosion  may  be  noted. 

Restoeative  Treatment. — If  the  eroded  areas  be  excavated  and 
filled,  the  erosion  may  proceed  about  the  edges  of  the  fillings.  It 
may,  however,  take  some  time  for  the  erosion  to  become  as  deep  as 
the  original  area. 

If  metal  be  used,  the  margins  must  be  extended  to  avoid  this,  if 
possible.  Metal  is  very  unsightly  in  many  locations  peculiar  to 
erosion,  so  that  porcelain  inlays,  which  the  locations  favor,  are 
indicated.  The  thinness  of  the  porcelain  and  change  of  color  by 
underlying  zinc  oxyphosphate  indicate  the  use  of  a  sihcate  cement 
as  the  lute  in  some  cases.  In  their  place  silicate  cement  fillings  may 
be  used,  but  must  be  constantly  kept  in  a  good  condition  of  surface 
or  they  become  unsightly. 

They  last  best  when  placed  under  the  rubber  dam.  The  writer 
has  a  case  of  six  upper  teeth  (the  cervical  half  of  the  teeth  involved) 
in  splendid  condition  after  five  years  of  service.  Screws  may  be 
introduced  to  hold  the  silicate  in  the  flatter  erosions.  (See 
Abrasion.) 

The  generally  distributed  erosions  are  only  amenable  to  the  prophy- 
lactic treatment  (except  by  crowning,  when  teeth  are  largely  wasted 
away),  and  slight  erosions  are  best  treated  in  the  same  manner.  If 
a  sharp  edge  be  produced  it  is  wefl  to  remove  it,  as  lip  irritation  may 
possibly  be  a  factor  in  the  acid  production,  and  also  tends  to  localize 
the  action  of  the  brush  bristle. 

MECHANICAL   INJURY   OF    THE    TEETH. 

The  enamel  is  a  material  much  more  brittle  and  inelastic  than  the 
dentin,  and,  therefore,  less  capable  of  resisting  a  parting  strain. 

1  Methods  of  Filling  Teeth, 


MECHANICAL  INJURY  OF  THE  TEETH 


225 


Fig.  241 


Under  ordinary  circumstances,  however,  well-formed  enamel  dis- 
tributed over  sound  dentin  resists  all  the  ordinary  forces  brought 
to  bear  upon  it. 

Under  abnormal  conditions,  however,  enamel  appears  to  fracture 
readily.     Dentin  may  apparently  fracture  in  any  plane. 

Causes. — The  teeth  may  be  mechanically  injured  by  (1)  the  action 
of  abrasion,  which  mechanically  wears  away  the  teeth;  (2)  by  the 
application  of  undue  force  during  mastication  or  by  the  improper 
use  of  cutting,  filling,  or   extracting  imple- 
ments; (3)  by  blows  of  some  sort,  delivered 
either  directly  upon  the  teeth  or  through  forc- 
ible closure  of  the  jaws,  as  the  result  of  a 
shock  or  blow  delivered  upon  the  rim  of  the 
jaw.     Possibly  by  expansion  of  gases  or  root 
fillings  causing  pressure  from  within.      (See 
Putrefaction  of  the  Pulp.) 

Aside  from  blows  or  bites  of  sufficient 
force  to  break  sound  teeth,  it  is  rare  to  find 
teeth  fractured  without  a  previously  acquired 
weakness  in  the  tooth  itself.  The  causes  of 
weakness  are  several. 

During  the  course  of  abrasion  the  enamel 
is  worn  to  a  sharp  edge,  which  is  readily 
fractured.  Oblique  splintering  occurs  in  the 
line  of  cement  substance  between  the  glob- 
ules. Longitudinal  cracks  from  incisal  to 
cervix  may  occur.  The  enamel  edges  become 
ragged  and  further  fracture  is  imminent. 
Thread  biting  produces  a  similar  but  localized 
condition  (Fig.  242J. 

Caries,  by  removing  the  natural  support  of 
the  enamel,  renders  this  brittle  material  subject 
to  fracture  in  ordinary  use.    The  removal  of 

dentin  from  both  the  mesial  and  distal  sides  of  a  crown  by  caries 
— e.  g.,  a  bicuspid — renders  the  buccal  or  lingual  section  liable  to 
fracture,  as  the  result  of  a  strain  delivered  between  the  cusps  and 
tending  to  wedge  them  apart.  This  accident  is  liable  to  occur  in 
proportion  to  the  lessening  of  the  healthy  dentin  between  the  cavities 
or  beneath  the  occlusal  fissure.  An  upper  incisor  so  decayed  would 
naturally  have  its  labial  section  fractured  away,  particularly  its 
incisal  half;  usually  with  an  obhque  fracture  running  to  the  labial 
cervix.  A  bicuspid  or  molar  usually  splits  off  obliquely  to  labial  or 
lingual  cervix  (Figs.  244  and  245). 
15 


Fracture  of  two  year's 
standing  with  pulp  vital 
and  a  lateral  tissue  growth 
resembling  granulation  tis- 
sue covering  the  root  face, 
would  explain  how  the 
case,  Fig.  243,  occurred. 
(Macdonald.) 


226     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

The  exposure  of  the  dentin  of  a  devitaHzed  tooth  to  the  saliva 
seems  to  weaken  it. 

While  these  principles  are  correct,  it  is  surprising  to  what  extent 
enamel  undermined  by  caries  may  retain  its  integrity  if  properly 
supported  by  an  adhesive  oxyphosphate  of  zinc. 

The  packing  of  cohesive  gold  against  frail  enamel  walls  renders 
them  liable  to  direct  fracture,  or  if  packed  so  as  to  permit  leakage 
the  wall  is  further  weakened  by  lactic  acid  produced  upon  its  under 
surface.  Again,  the  improperly  prepared  cavity  margin  may  be 
comminuted,  a  condition  favoring  the  recurrence  of  caries,  or  a  few 
rods  or  a  section  may  be  cracked  off  along  the  margin  of  a  fiUing. 


Fig.  242 


Fig.  243 


Abrasion  associated  with  fracture  of  the 
enamel. 


Root  fracture  and  reattachment  by  ad- 
ventitious dentin.   (From  a  specimen.) 


Gold  does  not  support  enamel  walls  so  well  as  oxyphosphate.  If 
built  over  comparatively  frail  walls  in  such  a  manner  as  to  protect 
them  from  direct  impact,  they  stand  fairly  well.  Inlays  of  gold 
serve  a  useful  purpose  in  this  connection. 

Some  amalgams  by  attendant  leakage  permit  gradual  weakening  of 
frail  enamel  walls.  The  use  of  a  cement  lining,  as  in  combination 
fillings,  is  distinctly  useful  both  as  a  support  and  prevention  of 
leakage. 

Johnson^  explains  fracture  after  filling,  where  the  enamel  walls 
were  previously  undermined  but  not  fractured,  upon  the  theory  that 
previous  to  filling,  the  pain  attendant  upon  mastication  brings  about 
a  temporary  disuse  of  the  diseased  tooth.  After  filling,  comfort 
ensues,  the  patient  again  uses  the  tooth,  and  fracture  occurs.  He^ 
suggests  the  successful  measure  of  cutting  away  frail  walls  and 
letting  the  strain  come  upon  the  filling.  This  cannot  always  be 
done.   Id  many  cases  of  approximal  cavities  as  in  incisors,  cracks  may 


>  Principles  and  Practice  of  Filling  Teeth, 
2  Text-book  Operative  Dentistry. 


MECHANICAL  INJURY  OF  THE  TEETH 


227 


be  seen  involving  the  incisal  boundary.  In  such  cases  the  support 
of  cement  replaced  if  necessary  often  tides  over  a  case  for  many  years. 

The  fractures  caused  by  blows  present  features  of  interest.  An 
actual  splitting  off  of  one  of  the  angular  portions  of  a  crown  may 
occur,  or  a  fracture  may  be  seen  resembling  one  sometimes  seen  in 
a  pane  of  glass,  the  result  of  a  light  blow  from  a  stone. 

In  the  latter  case,  the  cracks  radiate  from  a  central  crushed  spot, 
and  may  involve  only  the  enamel.  A  large  section  of  an  incisor  may 
be  fractured  away  and  include  the  labio-incisal  third  and  all  the 
lingual  section  of  the  crown  and  a  small,  obliquely  fractm^ed  portion 
of  the  root.  This  results  from  a  blow — the  exact  opposite  usually 
results  from  occlusal  strain. 


Fig.  245 


Oblique  fracture. 


Fracture  involving  the  bifurcation  of  the  roots. 


Longitudinal  cracks  in  the  enamel  of  otherwise  fairly  sound  teeth 
occur,  the  line  running  from  the  labial  edge  of  the  gum  to  the  incisal 
edge  of  an  incisor  (Fig.  242),  or  from  the  fissure  of  a  bicuspid  along 
the  enamel  to  the  summit  of  a  cusp,  or  from  the  cervical  margin  of 
an  approximal  cavity  to  the  gum  margin. 

These  lines  probably  indicate  that  force  has  been  applied,  sufficient 
to  cause  a  parting  of  the  enamel  cap  without  loss  of  continuity  in 
the  more  elastic  dentin.  Dryness  from  mouth  breathing  may  be  a 
possible  cause  of  cracks,  and  the  contact  of  excessively  hot  or  cold 
substances  has  been  advanced  as  an  hypothesis,  but  mostly  they  are 
found  in  cases  of  overworked  teeth.  Flagg  alternately  plunged 
teeth  into  boiling  water  and  melting  ice  without  producing  cracks, 
while  dryness  caused  them  in  the  same  teeth.  In  some  cases  the 
enamel  cracks  may  be  very  numerous.  The  large  cracks  take  up 
stains,  the  finer  ones  do  not,  as  a  rule,  and  can  often  be  seen  only 
by  throwing  the  tooth  into  a  shadow  by  means  of  the  finger,  and  at 
times  in  the  preparation  of  cavities,  cause  annoyance  by  centring 


228     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

the  chisel  and  perpetuatmg  a  defect,  necessitating  the  removal  of 
much  tooth  tissue  or  the  risking  of  future  caries.  In  one  case  typical 
of  a  class  of  accidents,  the  root  of  a  second  bicuspid  was  found  loose 
and  fractured  longitudinally  (Fig.  246).  As  its  occlusal  end  was 
firmly  embedded  in  an  encircling  crown  band,  and  no  pins  had  been 
used,  the  only  explanation  seems  to  be,  fracture  in  preparation,  the 


Fig.  246 


Fig.  247 


Case  of  root  fracture.    (See  Text.) 


Fracture  of  portion  of  upper  cuspid, 
cause  unknown.  (Radiograph  by  E.  Ball- 
ard Lodge.) 


swelling  of  the  guttapercha  root  canal  filling  or  the  expansion  of  gas. 
Such  an  explanation  could  not  apply  to  the  fracture  in  Fig.  247. 
Occasionally  a  root  of  a  multirooted  tooth  is  separated  from  its 
crown  by  fracture  even  when  not  weakened,  though  usually  caries 
has  acted.     Sudden  twisting  seems  to  be  the  cause. 


Fig.  248 


Fig.  249 


Fractured  molar  root. 


Longitudinal  fracture  of  molar  root. 


A  peculiar  case  is  shown  in  Fig.  250:  A  radiograph  of  longitudinal 
fracture  not  in  evidence  until  the  picture  was  taken.  There  was  no 
soreness  and  no  fracture  of  the  crown  though  largely  filled.  It  was 
merely  suspected  of  apical  granuloma.  (See  granuloma  for  further 
remarks.)     Fig.  249  shows  a  peculiar  longitudinal  fracture. 

The  case  in  Fig.  248  shows  a  fractiu-ed  root,  the  crown  being  intact. 


MECHANICAL  INJURY  OF  THE   TEETH  229 

Fracture  and  repair  of  enamel  after  eruption  is  not,  so  far  as  I 
am  aware,  known.  Cases  of  fracture  and  repair  of  dentin  have 
occurred. 

A  case  of  such  repair  by  adventitious  (secondary)  dentin  has  been 
recorded  by  Tomes,^  and  Fig.  243  illustrates  a  fractm-e  of  the  root 
well  below  the  gum  line.     The  root  is  girdled  by  the  line  of  fracture, 
but  the  dentin  has  been  repaired,  and 
the  attachment  is  firm.     The  line  evi-  ^^     250 

dently  indicates  a  repair  from  the  pulp 
side.  In  a  case  reported  by  Val.  INIac- 
donald,'-  of  a  similar  fracture,  the  pulp 
maintained  its  vitality  in  both  crown 
and  root  for  two  years,  and  until  the 
tooth  was  extracted.  There  was  be- 
tween crown  and  root,  a  growth  of  soft 
tissue  connected  with  both  the  pulp 
and  the  pericementum,  and  considered  Longitudinal  fracture  of  mesial 
by  Macdonald  to  be    pulpal  in  origin  '°°*  ^^  ^°^^"- 

(Fig.    241).    Macdonald's    case    would 

explain  that  in  Fig.  243.  A  case  analogous  to  healing  of  a  com- 
minuted fractm-e  of  a  central  has  been  reported.^  Fig.  250  illustrates 
a  peculiar  fracture  due  to  an  unknown  cause. 

In  an  experimental  implantation  of  a  dried  tooth,  filed  to  fit  the 
socket  of  a  previously  extracted  tooth,  union  of  osseous  nature  took 
place,  and  a  slight  fracture  of  the  root  was  reunited  by  osseous 
deposition.^ 

Treatment. — The  treatment  of  fractures  involves  considerations 
purely  operative,  and  depends  upon  the  nature  of  the  case.  Rough- 
ened, abraded  enamel  margins  are  best  rounded  with  carborundum 
stones  or  coarse  sand-paper  disks,  and  should  be  polished.  Ragged 
teeth  are  thus  much  improved  in  appearance  and  resistance  to 
further  fractures.  Sometimes  a  deep  serration  must  be  filled; 
corners  are  to  be  nearly  rounded  or  restored  to  contour  by  fillings 
or  inlays,  or  at  times  the  entire  incisal  edge  is  to  be  ground  away 
and  the  tooth  drawn  down  and  retained  until  firm. 

In  case  of  an  uncompleted  tooth  root,  and  the  pulp  not  quite 
exposed,  a  pure  gold,  all-metal  crown  is  to  be  adapted  with  or  without 
grinding,  according  to  the  future  requirements,  and  the  root  com- 
pletion awaited.     For  adaptation  to  the  neck  the  cervical  portion 

1  A  System  of  Dental  Surgery.    (See  Secondary  Dentin.) 

2  Dental  Cosmos,  January,  1908. 

3  Watson:  Dental  Record,  May,  1906. 

*  Mendel  Joseph  and  Dessonville:  L'Odontologie.    (See  Cosmos,  1904,  p.  1060.) 


230     NON-SEPTIC  AFFECTIONS  OF  THE  ENAMEL  AND  DENTIN 

may  be  slit  and  burnished  in.  If  necessary,  the  capping  of  the  pulp 
may  be  attempted  as  well,  for  the  same  purpose. 

After  root  formation  the  pulp  may  be  destroyed  if  desired.  If 
conservation  of  the  pulp  be  not  possible,  the  pulp  may  be  prepared 
for  removal  by  pressure  anesthesia  or  conductive  anesthesia,  and  the 
root  filled.    (See  Root  Fillings.) 

Fractures  involving  the  cementum  demand  either  the  removal  of 
the  loosened  piece  and  the  construction  of  a  special  crown  retaining 
a  portion  of  the  natural  crown  as  a  base,  or  the  removal  of  all  of  the 
natural  crown  and  the  mounting  of  a  substitute  upon  the  root.  In 
some  cases  the  remaining  portion  must  be  built  up  with  amalgam 
or  in  part  with  amalgam  as  a  base.  If  the  loosened  portion  be 
retained  it  is  apt  to  irritate,    and    in    most   cases  in   time   cause 


Fig.  251 


Fig.  252 


Oblique  fracture  of  root,  with  pin  and 
amalgam  for  restoration,  ready  for 
crowning.      (Evans.) 


Screws  placed  into  a  fractured  root  to 
enable  the  building  up  of  amalagam 
around  a  waxed  pin  attached  to  a  gold 
cap.  This  root  is  one  of  four  piers 
of  a  nine-tooth  bridge  in  place  ten  years 
to  date. 


lateral  abscess  with  possible  remote  systemic  complications.  These 
should  be  considered  very  carefully  and  contra-indicate  most 
attempts.  For  this  reason  fractures  involving  the  bifurcation  are 
unsuitable.  The  cuspid  root  shown  in  Fig.  252  had  an  amalgam  filling 
in  its  mesial  side  until  after  the  cap  and  band  were  constructed.  A 
temporary  crown  caused  the  wall  to  fracture  out,  so  the  plan  was 
devised  of  drilling  holes  in  the  root  side,  tapping  them  with  the  How 
tap  and  placing  iridioplatinum  screws  on  both  sides  of  the  pulp  canal 
groove.  The  pin  and  cap  were  then  waxed  slightly,  placed  in  posi- 
tion, amalgam  built  in  and  when  hard,  the  wax  was  melted  by  heating 
the  cap  and  pin,  which  were  withdrawn.  After  thorough  harden- 
ing, the  bridge-work  was  proceeded  with.  Fortunately  the  root 
received  its  strain  from  the  lingual  side,  which  was  largely  intact. 


MECHANICAL  INJURY  OF  THE  TEETH  231 

This  case  is  in  good  condition  after  ten  years  of  service.  In  a  case 
of  fracture  of  a  portion  of  root  side  not  of  such  magnitude  the  canal 
may  be  prepared  and  the  walls  of  the  aperture  of  fracture  beveled 
for  a  gold  inlay  which  may  have  a  pin  through  its  center  and  extend- 
ing further  up  the  canal  than  the  inlay  proper.  This  inlay  if  arranged 
to  "cope"  the  root  face  may  have  all  necessary  strength  for  the 
mounting  of  a  crown  upon  it.  The  requirements  vary,  and  must 
have  due  consideration. 


CHAPTER  VII. 

STAINS  OF  THE  ENAMEL  AND  DENTIN. 

Certain  stains  are  found  upon  the  surface  of  the  enamel  and  some- 
times penetrating  its  substance.  The  calculus  sometimes  located 
upon  the  enamel  is  not  included  in  this  consideration,  though  the 
calculus  itself  sometimes  becomes  stained.  So  far  as  they  have 
been  observed,  stains  may  be  divided  into  those  of  metallic  and 
non-metallic  origin. 

METALLIC   STAINS. 

Metallic  stains  are  those  which  are  caused  by  the  direct  depo- 
sition of  minute  particles  of  metal,  inhaled  by  workers  in  the  metals, 
in  the  organic  collections  upon  the  surfaces  of  the  teeth,  or  taken 
into  the  mouth  in  various  solutions  of  drugs. 

Copper. — Miller  found  that  "workers  in  copper,  brass,  or  bronze 
all  presented  a  green  stain  upon  the  upper  teeth,  showing  every  shade 
of  green  and  bluish-green  up  to  bluish-purple.  The  latter  color  pre- 
dominated in  rooms  where  phosphor-bronze  was  worked."  Attention 
is  called  to  the  fact  that  "trumpeters  very  often  show  a  discolor- 
ation of  the  teeth."  Similar  discolorations  are  sometimes  noted  in 
proximity  to  copper  amalgam  fillings.  The  presence  of  copper  was 
demonstrated  in  scrapings  from  some  of  the  stained  teeth,  imparting 
a  characteristic  green  color  to  a  Bunsen  flame.  McGeehee^  notes 
a  case  of  a  metal  worker  whose  enamel  was  stained  and  the  dentin 
as  well,  the  tooth  being  vital.  The  presence  of  defects  or  spaces 
containing  organic  matter  is  evidenced  (see  p.  143).  Bands  or  wires 
containing  base  metals,  generally  containing  copper,  sometimes  stain 
enamel. 

Iron. — "Workers  in  iron  presented  stains  of  a  brownish  color." 
As  pointed  out,  "the  green  salts  of  iron  under  the  conditions  found 
in  the  mouth  would  become  oxidized  and  brownish  in  color."  The 
administration  of  iron  salts,  medicinally,  is  believed  to  produce 
black  discolorations,  iron  sulphid  being  formed.  "Iron  deposits  are 
usual  in  the  border-line  between  carious  and  normal  dentin."  It  is 
believed  that  the  brownish  spots  frequently  seen  in  connection  with 

1  Dental  Cosmos,  March,  1912. 
(232) 


METALLIC  STAINS  233 

incipient  or  arrested  caries  of  the  enamel  are  due  to  the  formation 
of  iron  salts.    Iron  or  steel  in  dentin  stains  black  with  iron  sulphid. 

Manganese. — ]Manganese  was  found  in  the  dark  colored  deposits 
upon  the  teeth  of  herbivorous  animals,  but  as  yet  not  upon  those  of 
man.  The  investigator  stated  "that  alkaline  saliva  may  be  necessary 
to  the  production  of  these  deposits."  Manganese  stains  may  occur 
from  the  use  of  potassium  permanganate,  manganic  oxid  being 
formed. 

Mercury. — In  cases  of  prolonged  mercurial  administration  the 
deposits  (black)  upon  the  teeth  may  give  the  reaction  for  mercury. 
"If  mercury  and  potassium  iodid  are  given  together,  the  green  iodid 
of  mercury  might  be  present  upon  the  teeth."  It  is  probable  in  these 
cases  that  another  discoloring  substance  may  form.  There  is  in 
mercurialism  more  or  less  gingivitis;  the  gums  are  swollen  and 
spongy,  bleeding  readily.  "More  or  less  putrefactive  decomposi- 
tion of  the  albuminous  matter  present  upon  the  teeth  occurs,  and 
hydrogen  sulphid  is  formed.  Reacting  upon  the  ox;^^hemoglobin  of 
the  blood,  sulphomethmoglobin  is  formed — greenish  red  in  concen- 
trated, green  in  dilute  solutions."  Miller  ascribes  the  discoloration 
found  in  conditions  of  gingivitis  from  various  causes,  with  lack  of 
hygienic  care,  to  a  probable  reaction  between  hydrogen  sulphid  and 
oxyhemoglobin. 

Lead. — Hirt  (quoted  by  ]Miller)  found  in  cases  of  lead  poisoning, 
discolorations  upon  the  teeth :  dark  bro^Ti  at  the  necks,  light  brown 
on  the  cro\\Tis,  with  sometimes  a  trace  of  yellowish  green.  Miller's 
tests  (limited  in  number)  showed  no  lead  reaction  from  the  dental 
deposits  in  lead  poisoning. 

Nickel. — Some  of  the  salts  of  nickel  are  green.  jMetalhc  nickel 
attacked  by  fluids  of  the  mouth  and  mixtures  of  bread  and  saliva  pro- 
duces greenish  salts.  The  entire  root  of  a  tooth  containing  a  nickel 
retaining  screw  has  been  stained  a  uniform  apple  green. 

Silver. — The  dentin  of  pulpless  teeth  containing  amalgam  fillings 
is  sometimes  stained  black,  owing  to  the  formation  of  silver 
sulphid. 

The  use  of  silver  nitrate  as  a  wash  may  cause  the  albuminate  of 
silver  to  precipitate  salts  of  silver  upon  the  teeth.  If  a  cavity  be 
touched  with  silver  nitrate  and  an  amalgam  filling  be  introduced, 
the  salts  of  silver  will  be  instantly  formed  at  any  point  where  the 
silver  nitrate  and  amalgam  combine.  If  this  be  upon  the  enamel,  the 
latter  will  receive  a  somewhat  lasting  black  stain. 

The  nitrate  of  silver  applied  to  dentin  causes  the  dentin  to  assume 
a  light  yellowish  green  tinge,  and  the  albuminate  of  silver  is  formed; 
later  metalhc  silver  is  precipitated,  the  tissue  becoming  black. 


234  STAINS  OF  THE  ENAMEL  AND  DENTIN 

Nitschke^  has  called  attention  to  the  possibility  of  stained  roots 
showing  through  the  gums.  The  Howe  method  of  staining  roots 
for  sterilization  with  deposited  silver  should  be  used  with  care  as 
per  directions  to  avoid  the  possibility  as  well  of  crown  staining  (see 
Index). 

Gold. — Gold  chlorid  stains  may  be  formed  during  the  bleaching 
of  teeth  containing  gold  fillings  by  the  chlorin  methods.  The  dentin 
becomes  first  pink,  then  violet  or  purple,  then  black.^  They  must 
be  removed  for  this  method. 

NON-METALLIC    STAINS. 

Green  Stain. — The  most  common  of  green  deposits  upon  enamel 
occurs  upon  both  the  temporary  and  the  permanent  teeth,  particu- 
larly of  young  persons.  The  deposits  usually  have  a  crescentic  form, 
are  mainly  upon  the  labial  faces  of  the  anterior  teeth,  and  may  be 
but  a  narrow  line  or  may  cover  one-half  the  labial  face.  It  is  unusual 
for  the  deposit  to  extend  far  into  the  interproximal  spaces,  their 
tendency  being  to  follow  the  edges  of  the  approximal  surfaces.  While 
green  stain  undoubtedly  does  form  upon  adult  teeth  (Figs.  253  and 
254),  where  clearly  the  enamel  cuticle  has  long  been  absent,  it  is  only 

Fig.  253  Fig.  254 


Extension  of  green  stain  on  the  approx-  Extension  of  green  stain  on  the  lingual 

imal  surface  of  the  incisors.   (Miller.)  surface  of  the  incisors.  (Miller.) 

very  common  upon  young  teeth  where  remnants  of  Nasmyth's  mem- 
brane persist  about  their  necks.  The  color  of  these  deposits  varies 
from  light  green  to  greenish  black. 

If  an  instrument  be  passed  over  the  portion  of  enamel  affected, 
more  or  less  roughness  of  the  surface  is  evident.  If  the  deposits  are 
subjected  to  friction  with  abrasives,  they  disappear  slowly  and  the 
enamel  beneath  may  be  found  roughened.  This  has  led  to  the  belief 
that  these  deposits  cause  decalcification  of  the  enamel.  It  is  found 
upon  adult  teeth  that  when  an  area  of  cervicolabial  enamel  has 

1  Dental  Cosmos,  1918. 

2  Kirk:  American  Text-book  of  Operative  Dentistry. 


NON-METALLIC  STAINS  235 

become  roughened  through  slight  decalcification,  a  green  stain  is 
likely  to  form  upon  the  rough  surface,  if  proper  hygienic  care  be  not 
exercised.  It  is  also  found  that  if  the  stain  be  removed  by  means  of 
abrasives,  the  roughened  enamel  may  be  readily  polished — i.  e.,  the 
decalcification  is  very  superficial. 

If  cases  be  observed  early  enough  in  childhood,  it  will  be  noted  that 
green  stain  is  usually  preceded  by  a  lack  of  oral  hygiene;  collections 
of  food  debris  are  not  removed  from  about  the  necks  of  the  teeth, 
which  implies  that  prior  to  the  formation  of  green  stain  the  affected 
enamel  surfaces  have  been  subjected  to  the  action  of  fermenting 
food  debris — that  is,  to  acids.  These  facts  have  led  to  an  acceptance 
of  the  view  that  the  roughness  or  decalcification  has  preceded  the 
green  deposits,  but  the  writer  does  not  feel  certain  about  this.  "If 
teeth  be  placed  in  a  10  per  cent,  solution  of  hydrochloric  acid,  in 
from  two  to  four  minutes  the  enamel  cuticle  begins  to  loosen,  and  in 
from  five  to  ten  minutes  is  isolated.  It  is  found  that  the  entire 
stain  comes  away  with  the  cuticle." 

In  even  the  mouths  of  children,  the  removal  of  green  stain  with 
pumice  may  be  difficult,  showing  that  some  penetration  of  enamel 
substance  has  occurred. 

Nature  of  the  Coloring  Matter. — The  coloring  matter  is  found  to 
be  insoluble  in  water,  glycerin,  alcohol,  ether,  chloroform,  or  oil  of 
turpentine.  Mineral  acids,  hydrochloric,  nitric,  and  nitrohydro- 
chloric  act  but  slowly  upon  the  coloring  matter;  even  hydrochloric 
acid  requires  some  hours  to  completely  destroy  it.  Tincture  of 
iodin,  commonly  believed  to  act  as  a  solvent  of  green  stain,  w^as 
found  to  affect  it  but  slightly.  Both  chlorin  and  nascent  oxygen 
destroy  the  coloring  matter  rapidly,  the  cuticle  being  bleached  in  a 
few  minutes  by  a  10  per  cent,  solution  of  hydrogen  dioxid.  Thick, 
dark  green  deposits  were  incompletely  bleached  after  eight  hours' 
immersion  in  the  10  per  cent.  H2O2  solution,  pointing  to  a  lack  of 
uniformity  in  the  composition  of  the  stain. 

The  belief  that  the  green  coloring  matter  is  chlorophyl  is  contra- 
dicted by  the  fact  that  it  is  not  soluble  in  ether. 

Miller^  regarded  the  association  of  the  green  discoloration  with 
sulphomethemoglobin,  or  some  allied  substance,  as  the  most  probable 
explanation,  though  he  found  a  micrococcus  in  a  deposit  of  green 
stain  which  produced  a  grayish-green  color  in  glycerin  agar. 

Miller  did  not  find  any  definite  connection  between  a  milk  diet 
and  green  stain. 

Goadby^  has  found  Bacillus  liquefaciens  fluorescens  motilis  present 

1  Dental  Cosmos,  1894.  2  Mycology  of  the  Mouth. 


236  STAINS  OF  THE  ENAMEL  AND  DENTIN 

in  several  cases  of  green  stain.  It  deposits  in  its  culture  medium 
a  fluorescent  blue-green  pigment.  Other  mouth  bacteria  produce  a 
greenish  pigment — e.  g.,  Bacillus  pyocyaneus  and  Bacillus  fluorescens 
non-liquefaciens.^  The  Streptococcus  viridans  produces  a  green  pig- 
ment in  some  media. 

In  case  of  roughened  enamel,  green  stain  appears  at  times  to  have 
been  taken  into  its  substance,  rendering  removal  without  bleaching 
difl&cult. 

Black  Stain. — A  peculiar  black  stain  occurs  in  the  mouths  of  appar- 
ently healthy  individuals,  both  men  and  women,  and  smokers  and 
non-smokers,  and  even  with  those  also  who  drink  neither  tea  nor 
coffee.  It  occupies  the  general  position  described  for  green  stain, 
but  may  cover  much  of  the  surface  of  the  teeth.  It  occurs  in  some- 
what unclean  mouths,  though  the  teeth  may  have  been  regularly 
brushed.  As  a  rule,  those  teeth  having  the  deposit  are  comparatively 
free  from  caries.  Its  etiology  is  not  worked  out,  but  it  may  be  due  to 
a  formation  of  metal  sulphids  in  place  of  sulphomethemoglobin.  I 
have  asked  both  a  bacteriologist  and  a  histologist  to  examine  some 
of  this  pigment  but  without  result.  It  is  very  readily  removed, 
and  does  not,  as  a  rule,  affect  the  enamel.  At  times  a  superficial 
caries  is  found  associated  with  it,  and  at  some  minute  spot  the 
enamel  may  be  penetrated.  Whether  this  cavity  is  a  result  of  the 
action  of  the  film  is  not  certain.  In  a  case  of  a  woman  a  black 
stain  was  prevalent  for  years — recently  it  has  entirely  disappeared. 
The  only  available  explanation  other  than  some  possible  unknown 
systemic  change,  is  the  use  of  a  well-known  tooth  paste  which  con- 
tains a  large  percentage  of  potassium  chlorate. 

Tobacco  Stains. — Smokers  have  characteristic  black  deposits  upon 
both  the  teeth  and  calculus  deposited  upon  them.  The  stain  is  most 
marked  upon  the  lingual  surfaces  of  the  teeth,  and  a  pipestem  held 
well  back  in  the  mouth  may  cause  a  thick  deposit  upon  some  of 
the  posterior  teeth. 

Tobacco  juice  itself  stains  exposed  dentin  and  cementum,  and 
enters  cracks  in  the  enamel,  producing  brown  discolorations  very 
difficult  or  impossible  to  remove.  McGeehee  found  tobacco  stain 
to  have  deeply  penetrated  the  enamel  tissue. 

Stains  Due  to  Dyes, — McGeehee^  has  shown  that  colored  mouth 
washes  containing  vegetable  or  anilin  coloring  matter  may  stain 
enamel  and  other  tooth  structure.  The  chewing  of  betel  nut  or 
other  material  containing  vegetable  coloring  matter  also  produces 
a  stain  characteristic  of  the  coloring  element.    Dyed  cotton  also  stains. 

1  Mycology  of  the  Mouth.  ^  Dental  Cosmos,  March  1912. 


TREATMENT  OF  STAINS  237 

The  use  of  dilute  Talbot's  iodogylcerol  while  valuable  as  an  oral 
antiseptic  has  produced  unsightly  stains,  giving  a  coppery  look  even 
to  gold  inlays. 

Red  Stain. — A  peculiar  red  stain  occurs  upon  the  necks  of  some 
teeth,  but  is  not  generally  distributed.  It  is  probably  due  to 
chromogenic  bacteria,  as  it  is  only  found  on  unclean  surfaces. 

According  to  Goadby,^  Bacillus  prodigiosus,  Bacillus  rouge  de  Kiel, 
Bacillus  mesentericus  ruber,  Bacillus  roseus,  Sarcina  roseus.  Micro- 
coccus roseus,  and  other  micrococci  produce  a  red  pigment  in  at 
least  some  of  their  media. 

Sarcina  lutea  and  Sarcina  aurantiaca  produce  yellow  and  orange- 
colored  pigment  respectively.-  The  exact  relation  of  chromogenic 
bacteria  to  stains  is  not  worked  out. 

DENTIN   STAINS. 

Exposed  dentin  may  be  stained  as  enamel  is.  In  addition  it  may 
take  up  certain  stains  like  tobacco. 

Metallic  fillings,  such  as  amalgam,  containing  mercury,  silver, 
copper  or  cadmium  metals  which  combine  with  sulphuretted  hydro- 
gen to  form  sulphids,  may  cause  staining  of  dentin. 

Metallic  posts  containing  silver,  copper,  or  nickel,  or  made  of 
steel  or  iron  wire,  may  produce  sulphids  in  the  same  manner.  The 
dentin  may  also  be  stained  pink  by  hemoglobin  entering  the  tubules 
during  the  progress  of  venous  hyperemia.  This  finally  develops 
iron  sulphid.  The  dentin  may  also  be  stained  by  iron  sulphid  formed 
during  putrefaction  of  the  pulp,  by  the  action  of  ammonium  sulphid 
upon  the  iron  contained  in  the  hemoglobin  of  the  blood  undergoing 
decomposition.  Silver  nitrate  solutions  and  Howe's  preparation  also 
stains  dentin.  The  dentin  has  been  stained  by  the  dye  in  colored 
cotton. 

TREATMENT    OF    STAINS. 

Enamel  stains  are  best  removed  by  mechanical  means,  after  the 
removal  of  calculus  from  the  teeth.  (See  Salivary  Calculus.)  For 
this  purpose,  brush  wheels  and  rubber  cups  charged  with  pumice  and 
revolved  in  the  dental  engine  are  used  to  remove  the  accessible  por- 
tions of  the  stains  in  obstinate  cases.  Next  a  wood  point,  made  by 
sharpening  an  orange-wood  stick  or  hickory  shoe-peg  to  a  wedge- 
shape,  is  charged  with  the  pumice  and  rubbed  by  hand  over  all  the 
surfaces  not  reached  by  the  brushes  and  cups.     For  the  more  inacces- 

1  Mycology  of  the  Mouth.  2  Xbid. 


238  STAINS  OF  THE  ENAMEL  AND  DENTIN 

sible  situations,  the  point  is  to  be  mounted  in  a  Jack  or  other  porte 
polisher.  A  very  fine  linen  tape,  a  German  silver  or  steel  strip,  or 
flat  floss  silk  charged  with  pumice  will  remove  the  stains  at  the  con- 
tact points.  A  very  small  finishing  bur  or  dull  ordinary  No.  1  or 
No.  I  bur  is  useful  upon  lingual  surfaces  or  in  grooves. 

The  powdered  pumice  used  is  best  mixed  with  glycerin,  to  prevent 
the  flying  of  the  pumice  during  the  rapid  revolution  of  the  wheels. 
Saturation  of  the  stains  with  tincture  of  iodin  followed  by  a  douche 
of  water  renders  them  more  visible,  and  also  brings  to  view  the 
associated  bacterial  films  upon  the  teeth.  A  very  weak  solution  of 
hydrochloric  acid  or  ammonium  bifluorid  (tartasol)  may  be  momen- 
tarily applied  and  immediately  brushed  off  with  the  rubber  cup  and 
pumice. 

Register  recommends  the  use  of  1  per  cent,  hydrogen  dioxid,  to 
be  forcibly  sprayed  upon  the  gums  and  deposits  both  before  and 
after  the  use  of  tincture  of  iodin.  The  brush  and  pumice  will  then 
rapidly  remove  the  stains  and  bacterial  films  upon  the  accessible 
portions  of  the  teeth. 

Tobacco  stains  in  cementum  need  not  be  removed  to  their  full  depth. 

Head^  has  suggested  the  removal  of  deep  enamel  stains  and  the 
deposits  in  irregular  depressions  and  joints  of  inlays,  inaccessible  to 
the  stick,  by  the  use  of  nascent  oxygen  derived  from  25  per  cent, 
ethereal  pyrozone,  or  a  paste  of  sodium  dioxid  and  water,  made  by 
dissolving  the  latter  in  distilled  water  at  about  32°  F.  These  are 
applied  to  the  part  on  cotton,  and  nascent  oxygen  liberated  with  a 
hot  burnisher.  The  face  and  gums  are  protected  by  the  securely 
placed  rubber  dam  and  by  oiling  the  face. 

The  method  is  also  applicable  to  the  bleaching  of  obstinate  stains 
of  the  dentin,  especially  near  the  cutting  edges. 

In  the  joints  of  inlays,  fresh  cement  is  to  be  rubbed — preferably 
the  silicates — in  order  to  prevent  a  rediscoloration. 

If  beneath  green  stains  decalcification  be  discovered,  the  decal- 
cified area  should  be  polished  as  well  as  possible,  but  not  cut  away 
unless  carious  and  the  patient  urged  to  careful  prophylaxis. 

After  the  removal  of  calculus  and  stains  from  the  teeth,  the  mouth 
and  teeth  should  be  kept  in  as  cleanly  and  aseptic  a  state  as  possible, 
by  the  employment  of  correct  prophylactic  measures.  Dental  caries 
and  pyorrhea  alveolaris  are  thus  also  largely  prevented.  (See  Pro- 
phylaxis of  Dental  Caries  and  Pyorrhea  Alveolaris.) 

The  stains  found  in  the  dentin  are  also  divisible  into  metallic  and 
non-metallic.  The  former  are  best  removed  by  transforming  the 
insoluble  metallic  salt  into  a  soluble  one. 

1  Items  of  Interest,  1902. 


TREATMENT  OF  STAINS  239 

The  most  frequent  and  practicable  course  is  to  form  soluble  chlorids 
through  the  action  of  nascent  chlorin.  Copper,  nickel,  gold,  and 
iron  stains  should  be  subjected  to  the  chlorin  method  of  bleaching, 
followed  by  repeated  washings  with  chlorin  water,  50  per  cent.,  and 
hot  distilled  water  to  remove  the  chlorid  formed.^ 

Silver  stains  are  converted  into  silver  chlorid  by  the  chlorin 
method,  or  iodid  by  the  use  of  tincture  of  iodin,  and  dissolved  out  by 
the  use  of  sodium  hyposulphite,  followed  by  hot  distilled  water.^ 

For  mercurial  stains  Kirk  recommends  the  use  of  aqueous,  ammo- 
niacal  solution  of  hydrogen  dioxid  after  the  chlorin  method,  and  a 
saturated  solution  of  potassium  iodid  after  the  iodin  method,  in 
either  case  followed  by  washing  with  hot  distilled  water. 

Manganese  stain  is  removable  by  the  use  of  25  per  cent,  aqueous 
solution  of  hydrogen  dioxid,  saturated  with  oxalic  acid  crystals  and 
followed  by  washing  with  hot  water. 

The  non-metallic  dentin  stains  are  removable  by  the  use  of  chlorin 
evolved  from  chlorinated  lime  by  the  reaction  with  dilute  acetic 
acid,  or  of  nascent  oxygen  evolved  from  hydrogen  dioxid  or  sodium 
dioxid. 

In  either  case  the  color  molecule  is  destroyed  by  the  indirect  or 
direct  oxidizing  effect. 

The  hydrogen  dioxid  may  be  used  in  the  form  of  the  25  per  cent, 
ethereal  solution  (25  per  cent,  pyrozone)  applied  for  a  time,  or  sealed 
within  the  tooth  for  twenty-four  hours,  or  the  25  per  cent,  aqueous 
solution  may  be  driven  into  the  tubuli  by  the  aid  of  the  cataphoric 
current. 

Sodium  dioxid  should  be  employed  in  saturated  solution  in  distilled 
water  (made  at  about  32°  F.).  The  dentin  is  first  desiccated  and 
then  saturated  with  the  solution.  Weak  sulphuric  acid  (10  per 
cent.)  is  used  to  liberate  the  nascent  oxygen.  Kirk  recommends  a 
second  application,  omitting  the  use  of  the  acid. 

As  with  metallic  stains,  all  the  by-products  should  be  washed  out 
with  hot  distilled  water,^ 

A  further  description  will  be  given  under  the  caption  of  Putrefac- 
tion of  the  Pulp. 

1  Kirk:   American  Text-book  of  Operative  Dentistry.  ^  Ibid. 

3  For  a  complete  description  of  the  bleaching  process,  see  Kirk's  article  in  American 
Text-book  of  Operative  Dentistry. 


SECTION  Y. 

DENTAL  CARIES  AND  HYPERSENSITIVE 
DENTIN. 


CHAPTER   VIII. 

DENTAL  CARIES:  HISTORY;  EXCITING  AND  PRE- 
DISPOSING CAUSES. 

Definition. — Dental  caries  may  be  defined  as  a  disease  of  a  tooth 
characterized  chiefly  by  the  production  of  a  localized  cavity,  con- 
cavity, or  area  containing  decalcified  tooth  structure  and  due  to  a 
combined  acid  fermentation  and  liquefaction. 

History. — Examinations  of  crania  show  the  disease  to  be  certainly 
as  old  as  semicivilization,  and  when  more  data  are  obtainable  it 
will,  no  doubt,  be  found  even  older.  The  skull  of  a  mummy  in  the 
British  Museum,  dating  2800  B.C.,  exhibits  well-marked  caries  and 
other  dental  diseases.  Caries  appears  in  the  teeth  of  the  skulls  of 
all  peoples,  no  matter  what  their  degree  of  civilization,  provided 
their  dietary  included  cooked,  starchy  foods. 

Causes. — These  may  be  divided  into  exciting  and  predisposing. 

Prior  to  the  investigations  of  Miller,^  published  in  1882,  a  vast 
amount  of  labor  was  expended  in  the  effort  to  determine  the  cause 
of  dental  caries.  The  deductions  made  were  partly  speculative  and 
partly  based  upon  scientific  investigations. 

From  1754  to  1835  caries  was  regarded  as  an  infiammation  or 
gangrene  of  tooth  structure;  Boudett,  Jourdain,  Hunter,  Fox,  Bell, 
Fitch,  and  Koecker  advancing  one  or  the  other  theory.^ 

In  1835  Robertson,^  of  Birmingham,  England,  advanced  the 
opinion,  based  upon  his  observations,  that  it  "  is  to  chemical  and  not 
to  inflammatory  action  that  the  destruction  of  the  teeth  must  be 
attributed."  The  author  pointed  out  forcibly  the  errors  and  fallacies 
of  previous  writers.     He  stated  that  "Particles  of  food  retained  in 

1  International  Dental  Journal,  1884. 

^  For  an  interesting  and  exhaustive  exposition  of  their  views,  see  American  System 
of  Dentistry,  Section  on  Dental  Pathology,  by  Black. 

5  A  Practical  Treatise  on  the  Human  Teeth,  second  edition,  Philadelphia,  1839. 
16  (241) 


242  DENTAL  CARIES 

fissures  and  imperfections  of  the  teeth  and  in  the  spaces  between  the 
teeth  undergo  a  process  of  decomposition  and  acquire  the  property 
of  corroding,  disuniting,  and  therefore  destroying  the  earthy  and 
animal  substances  of  which  the  teeth  are  composed." 

John  Tomes,  a  Httle  later,  was  the  first  to  record  microscopic 
examinations  of  carious  dentin.  He  described  the  transparent  zone 
lying  between  the  carious  and  non-carious  dentin,  and  observed  and 
pointed  out  also  the  dentinal  fibrillse.  He  announced  the  very 
significant  fact  in  relation  to  caries,  that  if  blue  litmus  paper  be 
applied  to  a  carious  cavity  it  is  at  once  reddened,  which  furnishes 
evidence  of  the  presence  of  an  agent  capable,  if  unresisted  by  the 
vitality  of  the  dentin,  of  depriving  the  tissue  of  its  earthy  constitu- 
ents, leaving  the  "gelatin  to  undergo  a  gradual  decomposition 
favored  by  the  heat  and  moisture  of  the  mouth." 

Tomes  first  established  the  essentially  chemical  character  of  some 
features  of  caries.  The  character  of  the  acid  and  its  localization  were, 
however,  not  ascertained. 

In  1867  Bridgman  promulgated  the  theory  that  the  crown  of  the 
tooth  and  the  gum  were  of  different  electrical  potential,  and  that 
being  bathed  in  the  oral  fluids,  the  conditions  of  a  battery  were  set  up. 

Acid  substances  were  said  to  be  set  free  at  the  positive  pole  (the 
CTown),  causing  decalcification. 

S.  B.  Palmer,  in  1874,  claimed  that  after  filling,  recurrent  caries  was 
caused  by  the  conditions  of  a  battery  being  set  up — i.  e.,  the  differ- 
ence of  electrical  potential  between  the  filling  and  dentin  in  the 
presence  of  saliva  or  of  the  fluid  of  the  dentin,  as  an  electrolyte 
caused  liberation  of  acids,  producing  decalcification  of  the  tooth  or 
disintegration  of  the  filling — e.  g.,  oxyphosphate. 
"  Miller,  in  1881  and  1900,^  experimentally  examined  these  assump- 
tions. He  ground  the  enamel  away  from  the  crowns  of  freshly 
extracted  teeth  and  filled  cavities  made  in  them  with  gold  and  gutta- 
percha. These  he  placed  in  separate  flasks  containing  a  physiological 
salt  solution  (0.75  per  cent,  sodium  chlorid).  This,  in  the  presence 
of  electric  currents,  should  produce  hydrochloric  acid  by  liberation  of 
hydrogen  and  chlorin,  and  decalcification  should  occur.  After  four 
years  there  was  no  decalcification. 

Similarly  filled  teeth  were  suspended  in  dilute  lactic  acid.  The 
decalcification  was  exactly  similar  to  that  in  the  unfilled  pieces  used 
as  a  control.  Had  electrolytic  currents  been  generated  between  the 
metals  and  dentin,  the  latter  would  have  been  acted  upon  more 
vigorously  than  in  the  unfilled  pieces. 

1  Dental  Cosmos,  April,  1901. 


EXCITING  CAUSES  243 

In  1868  Watt^  advanced  the  theory  that  free  sulphuric,  nitric,  and 
hydrochloric  acids  were  generated  in  the  mouth  during  putrefactive 
processes  and  caused  the  different  varieties  of  caries. 

Magitot^  pointed  out  that  the  essential  phenomena  of  caries,  as 
they  were  then  understood,  were  the  same  in  natural  teeth  mounted 
upon  plates  as  in  the  natural  organs  in  situ;  proving  that  caries  is 
intrinsically  independent  of  existence  of  vitality.  By  immersing 
teeth  in  solutions  of  sugar  undergoing  fermentative  changes,  he  found 
that  decalcification  occurred.  Teeth  immersed  in  solutions  of  sugar, 
in  which  fermentation  had  been  prevented  by  boiling  the  solution 
and  sealing,  or  by  additions  of  sufficient  carbolic  acid,  remained 
unaffected. 

Leber  and  Rottenstein,  in  1867,  first  called  attention  to  the 
probable  causative  association  of  bacteria  with  some  phases  of 
dental  caries.  By  staining  carious  dentin  with  iodin,  the  dilated 
dentinal  tubules  were  shown  to  be  filled  with  granular  bodies,  which 
they  recognized  as  bacteria,  identifying  but  one  of  the  many  forms 
of  oral  bacteria — the  leptothrix.  They  deemed  an  initial  exposure  of 
dentin  a  necessary  preliminary  to  the  invasion  and  growth  of  the 
leptothrix,  which  in  conditions  of  lessened  resistance  gained  access  to 
the  tubules  and  in  some  undescribed  manner  caused  their  dilatation. 

The  question  of  the  recognition  of  the  presence  of  bacteria  directly 
resolves  itself  into  the  subject  of  special  staining.  Prior  to  the  work 
of  Koch,  presented  in  1881,  no  means  of  isolating  specific  bacteria 
by  special  cultures  and  staining  were  known,  and  it  is  remarkable 
that  in  the  same  year,  the  essential  features  of  dental  caries  were 
first  made  out  with  some  degree  of  clearness. 

Miles  and  Underwood  (World's  Medical  Congress,  1881)  pointed 
out  clearly  and  at  length,  the  different  appearances  produced  by 
simple  decalcification  of  dentin  and  those  by  dental  caries.  Speak- 
ing of  Magitot's  experiments,  they  say:  "We  assume  that  two 
factors  have  always  been  in  operation:  (1)  The  action  of  acids  and 
(2)  the  action  of  germs.  When  caries  occurs  in  mouths  it  is  always 
under  circumstances  more  favorable  to  the  action  of  germs  than  to 
the  action  of  acids."  They  believed  that  the  acids  necessary  for 
the  decalcification  were  excreted  by  the  germs,  which  utilized  the 
dentinal  fibrillee  as  a  food  supply. 

It  will  be  seen  that  the  invasion  and  multiplication  of  organisms  in 
the  tubuli  were  held  as  the  antecedent  of  the  process  of  decalcifica- 
tion. The  deductions  of  these  observers  were  drawn  from  data 
not  derived  from  the  methods  of  modern  bacteriology — i.  e.,  special 

1  Chemical  Essays,  1868. 

'  Treatise  on  Dental  Caries,  Experimental  and  Therapeutical  Investigations. 


244  DENTAL  CARIES 

stains  and  special  cultures.  Moreover,  they  were  made  before  the 
physiological  chemistry  of  bacteria  was  even  partially  understood. 

In  1882  W.  D.  Miller,  of  Berlin,  announced,  as  the  results  of 
experiments  conducted  by  him,  that  he  believed  the  first  stage  of 
dental  caries  to  consist  of  a  decalcification  of  the  tissues  of  the  teeth 
by  acids  which  are  for  the  greater  part  generated  in  the  mouth  through 
fermentation  of  carbohydrate  food  by  bacteria.  This  was  in  agree- 
ment with  the  clinical  deduction  of  Robertson,  of  England. 

The  observations  of  Miller  were  supplemented  by  J.  Leon 
Williams,  who  demonstrated  a  microbic  collection  upon  the 
surface  of  superficially  decayed  enamel,  and  having  suSicient 
attachment  to  permit  grinding  in  situ.  Williams  claimed  that 
these  plaques  are  the  primary  agents  which  manufacture  acid  from 
carbohydrate  material  in  association  with  them. 

These,  and  other  observers  whose  names  will  be  mentioned  in 
place,  have  thrown  side-lights  upon  the  formation  and  nature  of  the 
plaque  and  upon  the  pabulum  which  they  require  and  out  of  which 
they  form  acid  as  one  of  their  by-products. 

The  reader  will  be  assisted  in  considering  the  somewhat  discon- 
nected facts  hereafter  given  by  bearing  in  mind  the  generally  accepted 
theory  of  the  modus  operandi  of  caries  deduced  from  the  facts  brought 
out  and  which  is  now  briefly  stated.  The  'primary  cause  of  dental 
caries  is  a  collection  of  bacteria  upon  the  surface  of  the  tooth.  This 
probably  begins  with  a  coating  of  the  tooth  by  saliva  in  which  a 
certain  proportion  of  solid  organic  matter  exists — mucin,  globulin, 
leukocytes,  epithelial  scales,  etc. 

This  is  immediately  infected  by  ever-present  bacteria,  which  form 
colonies  in  it.  This  mass  of  organic  basis  and  bacterial  colonies 
when  firmly  established  can  be  ground  in  situ  and  constitutes  a 
"microbic  plaque."  By  itself  this  cannot  produce  dental  caries. 
To  this  microbic  plaque  comes  the  carbohydrate  food  which  is  the 
second  essential  factor  in  caries. 

Kirk^  states  that,  owing  to  the  presence  of  carbohydrate  and 
bacteria,  lactic  acid  is  formed  which  precipitates  mucic  acid  out  of 
mucin  in  which  it  exists  in  combination  with  an  alkaline  base.  He 
describes  mucic  acid  as  opalescent,  adhesive  and  insoluble  except 
in  an  alkaline  or  saline  solution. 

He  states  that  when  caries  is  in  active  progress  the  saliva  is 
ordinarily  acid  in  mucin,  rendering  it  ropy.  That  it  is  neutral  or 
faintly  alkaline  in  reaction.  That  if  lactic  acid  be  added  to  it  in 
a  test-tube,  mucic  acid  will  be  set  free  as  an  opalescent  precipitate 

1  Chapters  on  Caries,  Fones,  Mouth  Hygiene,  p.  196. 


EXCITING  CAUSES  245 

from  the  alkaline  base  with  which  it  was  chemically  combined  as 
mucin. 

There  was  exception  taken  to  this  theory  by  Miller,  who  claimed 
that  plaque  formation  was  not  essential,  but  that  the  infected  food 
mass  could  form  the  acid  and  act  directly.  This  is  simply  a  question 
of  whether  bacteria  act  in  the  mass  or  under  the  mass,  and  is  only 
a  question  of  modus  operandi,  not  of  essential  fact.  PickerilP  endorses 
Miller's  viewpoint,  but  so  far  as  the  writer  is  aware  neither  Miller  nor 
Pickerill  have  offered  any  satisfactory  proof  that  the  plaque  which 
von  Beiist  has  shown  to  form  in  a  few  hours  is  not  the  localizing 
factor.  There  is,  indeed,  no  reason  why  an  infected  food  mass  should 
not  form  its  own  underljdng  plaque  out  of  there  existing  mucin  and 
bacteria.  The  theory  of  self  solution  of  base  of  attachment  of  the 
plaque  (reason  2^)  seems  weak  in  view  of  the  rapidity  of  bacterial 
reproduction. 

In  either  case  after  bacterial  fixation  the  carbohydrate  is  changed 
by  the  bacteria  to  acid,  mainly  lactic  acid.  This  decalcifies  the 
tooth  substance,  leaving  the  organic  matrix.  The  organic  matrix  is 
next  destroyed  by  bacteria  having  the  power  of  its  liciuefaction, 
probably  due  to  their  enzymes.  Both  the  inorganic  and  organic 
bases  of  tooth  structure  being  destroyed,  a  cavity  is  left.  This 
being  a  relatively  slow  process,  the  intermediate  stages  are  found. 

Miller's  observations  and  experiments  established  the  following 
basal  facts  in  connection  with  dental  caries: 

1.  That  in  all  cases  of  dental  caries  microorganisms  may  be  seen 
under  the  microscope  in  the  tubules  of  the  carious  dentin,  and  that 
bacteria  exist  in  great  numbers  in  the  mouth. 

2.  That  the  invasion  of  the  tubules  is  always  preceded  by  decal- 
cification of  the  dentin — i.  e.,  an  area,  sometimes  relatively  large, 
of  decalcified  dentin  may  be  seen  in  advance  of  the  organisms. 

3.  Analysis  of  the  softened  dentin  proved  that  a  large  part  of  its 
lime  salts  were  removed — i.  e.,  decalcification  had  occurred. 

4.  Test  with  litmus  paper  gave  the  acid  reaction  in  nearly  every 
case,  so  that  the  inference  that  decalcification  was  due  to  an  acid 
was  warrantable. 

5.  The  food  substances  taken  into  the  mouth  are  of  all  classes. 
Carbohydrates  (sugars  and  starches),  hydrocarbons  (fats),  and 
nitrogenous  (albuminous)  materials. 

The  carbohydrates  are  fermented  with  acid  reaction  by  many 
mouth  bacteria,  commonly  producing  lactic  acid;  the  albumins 
ferment  with  an  alkaline  reaction. 

1  The  Prevention  of  Dental  Caries  and  Oral  Sepsis,  2d  Ed.,  p.  24.  ^jbid. 


246  DENTAL  CARIES 

It  was  inferred  from  this  and  other  experiments  that  caries  was 
due  to  the  acid  fermentation  of  carbohydrates  and  not  directly  to 
the  fermentation  of  albuminous  substances. 

6.  That  oral  fermentation  is  the  result  of  bacterial  action,  his 
following  fundamental  experiments  show: 

(a)  A  small  tube  was  filled  with  a  solution  of  starch  and  fastened 
to  a  molar  tooth  on  retiring.  The  next  morning  the  contents  of  the 
tube  had  a  strong  acid  reaction.  A  tube  of  the  starch  solution  with 
saliva  added  was  incubated  at  blood  temperature.  After  four  or 
five  hours  the  mixture  became  acid. 

(b)  The  mixture  of  starch  and  saliva  was  kept  at  100°  C.  for  a  half- 
hour,  and  incubated.  It  did  not  become  acid — i.  e.,  the  exposure  to 
this  temperature  killed  the  ferment. 

(c)  The  saliva  was  boiled  for  a  half  hour  and  then  added  to  the 
starch  solution  and  the  mixture  incubated.  No  acid  was  produced — 
i.  e.,  the  ferment  existed  in  the  saliva,  not  in  the  starch. 

{d)  The  ptyalin  of  the  saliva  was  destroyed  by  heating  the  mixture 
for  twenty  minutes  at  67°  C;  the  incubated  mixture  still  became 
acid — i.  e.,  ptyalin  did  not  act  as  the  acid-forming  ferment,  but  the  fer- 
mentation must  have  been  caused  by  some  other  ferment  not  destroyed 
by  exposure  to  this  temperature.      (Some  sugar  probably  formed.) 

(e)  To  the  mixture  of  saliva  and  starch,  carbolic  acid  was  added 
as  an  antiseptic.  No  acid  was  formed,  but  the  ptyalin  changed  the 
starch  to  sugar — i.  e.,  the  acid-forming  bacteria  were  inhibited,  the 
ptyalin  not. 

(/)  A  number  of  tubes  were  each  supplied  with  a  small  quantity  of 
the  saliva-starch  solution  and  sterilized;  a  third  of  them  were  infected 
from  the  mouth,  a  third  by  carious  dentin,  and  a  third  were  left 
uninfected  as  controls.  The  infected  tubes  became  acid;  the  controls 
did  not. 

(g)  The  first  of  a  series  of  tubes  containing  sterilized  saliva  and 
starch  solution  was  infected  with  carious  dentin;  when  this  became 
acid  a  fraction  of  a  drop  was  carried  from  it  to  a  second  tube.  After 
that  became  acid  a  third  was  infected  from  it,  and  so  on  indefinitely. 

Conclusion. — Carious  dentin  contains  a  ferment  or  ferments  cap- 
able of  reproduction — i.  e.,  living  organisms  are  present  in  it. 

7.  The  nature  of  this  living  ferment  was  determined  by  infecting 
a  culture  medium  with  carious  dentin  taken  from  the  deeper  layers. 
The  bacteria  cultivated  were  distended  into  pure  cultures  by  carry- 
ing through  a  series  of  cultures  and  examining  microscopically  during 
the  process.  The  same  morphological  characteristics  were  exhibited 
in  the  last  tube,  as  shown  by  the  germs  in  the  deeper  layers  of  carious 
dentin  itself,  and  were  identical  with  that  of  Bacterium  acidi  lactici. 


EXCITING  CAUSES 


24/ 


These  germs  may  be  found  in  the  sediment  of  a  culture  tube,  and 
consist  of  cocci  and  micrococci,  either  single  or  in  chains.  These 
cocci  possess  the  power  of  forming  lactic  acid  from  glucose.  The 
organism  is  a  facultative  anaerobe  (Fig.  255). 

8.  A  sound  bicuspid  was  sawed  into  sections,  and  an  equal  number 
of  these  sections  placed  in  each  of  two  test-tubes.  Upon  these  was 
poured  a  2  per  cent,  aqueous  extract  of  beef  (albuminous).  To  one 
tube  a  minute  portion  (0.2  per  cent.)  of  cane-sugar  was  added.  Both 
tubes  were  sterilized,  and  after  cooling  infected  with  a  pure  culture 
of  the  germ,  obtained  from  the  deeper  layer  of  carious  dentin.  The 
sugar-containing  solution  became  acid  in  a  few  hours;  in  a  week  the 
dentin  was  softened;  in  two  weeks  thin  sections  were  completely 
decalcified ;  in  three  weeks  cavities  were  found  in  the  dentin,  exactly 
similar  to  cavities  formed  in  teeth  in  the  mouth  and  presenting  under 
the  microscope  other  phenomena  of  caries  to  be  described  later. 


Fig.  255 


Fig.  256 


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A  more  prolonged  fermentation  resulted  in  the  complete  disintegra- 
tion of  the  slabs  of  dentin,  a  proof  of  the  fact  that  one  organism  may 
completely  destroy  dentin. 

In  the  tube  containing  only  the  extract  of  beef,  no  acid  was  pro- 
duced, and  no  decalcification  of  the  dentin  occurred. 

From  these  facts.  Miller  argued  that  putrefaction  does  not  initiate 
the  process  of  dental  caries,  and  may  not  be  essential  to  the  destruc- 
tion of  either  the  inorganic  or  organic  dental  elements. 

9.  That  the  acid  produced  was  lactic  acid,  Miller  demonstrated 
as  follows: 

Starch  and  saliva  were  mixed  and  fermentation  induced.  This 
was  then  checked  by  sterilization  with  heat.  A  quantity  of  material 
being  collected  in  this  manner,  the  whole  was  concentrated  by 


248  DENTAL  CARIES 

evaporation^  and  tested  with  a  solution  of  methyl  violet,  which 
would  turn  first  blue  and  then  green  with  an  inorganic  acid.  Not 
so  reacting,  and  not  distilling  off  during  the  concentration,  the  acid 
present  was  pronounced  a  non- volatile  organic  acid.  The  concen- 
trate was  shaken  with  a  quantity  of  ether,  which  dissolved  the  organic 
acid  present.  When  the  solution  was  clear,  it  was  filtered  and  the 
ether  partially  distilled  off,  when  the  partially  concentrated  solution 
was  further  concentrated  over  a  water  bath  and  then  mixed  with  an 
excess  of  freshly  prepared  zinc  oxid.  The  whole  was  boiled,  water 
being  added  as  needed,  until  the  solution  became  neutral,  when  it 
was  set  aside  to  crystalhze.  A  drop  placed  upon  a  slide  under  the 
microscope  showed  the  forms  of  crystals  of  zinc  lactate  (Fig.  256). 

By  testing  the  molecular  weight  of  the  washed  and  dried  crystals 
it  was  determined  clearly  that  the  substance  was  zinc  lactate. 

In  practically  a  similar  manner,  lactic  acid  was  obtained  directly 
from  carious  dentin. 

While  Miller  demonstrated  the  ability  of  one  organism  to  produce 
all  the  essential  phenomena  of  caries,  including  liquefaction  of  the 
dentin,  he  did  not  claim  that  only  one  or  two  organisms  are  involved 
in  the  process,  but  that  "  any  germs  possessing  the  power  of  producing 
acid  fermentation  of  food  may  and  do  take  part  in  the  first  stage  of 
caries,  and  that  all  those  possessing  a  peptonizing  or  digestive  action 
upon  albuminous  substances  may  take  part  in  the  second  stage; 
and  that  those  possessing  both  properties  may  take  part  in  both 
stages."^ 

He  was  of  the  opinion  that  it  is  not  the  presence  of  this  or  that 
kind  of  bacterium,  but  rather  the  joint  activity  of  the  total  flora, 
as  expressed  in  intensity  of  fermentation  in  food  particles,  which 
determines  the  extent  of  caries. 

Out  of  eighteen  mouth  bacteria  examined,  Miller  found  ten  that 
produced  lactic  acid  in  sugar-containing  solutions.^  He  also  found 
acetic  and  butyric  acid  to  be  by-products.  Miller  and  others  have 
found  lactic-acid-producingbacteria  plentiful  in  the  mouths  of  immune. 

Hinkins  and  Acree,^  in  experiments  upon  pure  cultures  of  a  number 
of  oral  bacteria  in  various  artificial  media,  found  lactic,  butyric, 
valerianic,  formic,  carbonic,  and  hydrosulphuric  acids  as  either 
principal  or  by-products  of  the  fermentation. 

Hartzell  and  Hem-ici*  believe  that  the  Streptococcus  brevis  of 
Lingelsheim,  Streptococcus  viridans  of  Schottmiiller,  Streptococcus 
salivarius  of  Andrews  and  Horder  and  diplococcus  of  Poynton  and 

1  Microorganisms  of  the  Human  Mouth. 

^  Ibid.  s  Dental  Cosmos,  1901. 

^  Jour.  Nat.  Dent.  Assn.,  May,  1917,  p.  491. 


EXCITING  CAUSES  249 

Paine  are  one  and  the  same  organism.  The}'  confirm  by  their 
observations  Goadby,  Kantorowicz  and  Xiedergestiss  in  finding  them 
in  deep  layers  of  decalcified  dentin,  piu'ely  gangrenous  pulp  and 
chronic  apical  abscesses  and  graniilomata,  and  also  upon  tooth 
sm-faces,  in  pyorrhea  pockets.  They  find  them  actually  increased 
in  numbers  in  carious  conditions  and  that  they  are  powerful  acid 
formers.  Thus  they  belie^'e  they  have  established  a  chain  of  evi- 
dence. The  associate  bacteria  of  caries  are  regarded  as  adjunct 
acid  formers  or  saprophytes  destroying  the  matrix.  Gies  and 
Kligler^  state  that  in  dental  caries  there  is  a  great  increase  in  the 
total  number  of  bacteria  in  the  mouth  accompanied  by  a  drop  in 
the  relative  number  of  cocci  and  a  marked  increase  in  the  niunber 
of  acidific  bacilli  and  thread-forming  organisms.  They  refer  here 
by  "cocci"  especially  to  streptococci.  (Later  Hartzell  and  Henrici 
pointed  out  that  though  relatively  decreased  they  are  numerically 
increased.) 

They  arri\-ed  at  the  tentative  opinions^  expressed  below  which 
we  condense: 

1.  The  oral  flora  changes  from  that  with  normal  teeth  and  a 
specific  infection  occiu-s  in  which  a  limited  niunber  of  types  of  bac- 
teria (perhaps  three)  are  concerned  in  primary  caries  of  enamel 
particularly  a  pleomorphic  thread-forming  organism  which  may 
cause  attachment  of  the  plaque  and  attach  other  forms  as  they  do 
in  the  test-tube  and  plates,  also  a  marked  increase  in  the  nimiber 
of  acidific  bacilli  which  attach  themselves  in  compact  colonies  to 
any  siu-face.  They  name  (a)  Bacillus  acidophUns,  {b)  Cladothrix 
ylacoides  and  (c)  Leptothrix  hiiccalis  as  prominent  in  carious  enamel 
deposits  (incipiency) ;  a  and  h  grow  vigorously  m  each  other's 
presence,  are  actively  fermentative  of  common  sugars  and  resist  high 
amounts  of  their  acidific  products.  They  do  not  exclude  coccus 
forms  as  a  possible  cause  of  acid  production. 

2.  There  is  a  distinct  difference  between  the  tj-pes  of  bacteria 
in  the  early  stages  and  those  in  the  later  periods  of  decay  which  they 
regard  as  modifymg  Howe  and  Hatch's  discoveries  of  acidific  bacteria 
in  dentm  (see  page  250) . 

They  also  give  interesting  data  upon  the  effects  of  brushing  and 
presence  of  food  particles  upon  the;  numbers  of  bacteria  present  in 
the  mouth.  Two  typical  examples  may  be  cited:  K  before  brush- 
ing m  the  morning  had  65,000,000  bacteria  in  each  miUigram  of 
specimen  material  and  15,000,000  after  brushing;  H  had  4,000,000 


^  Journal  of  Allied  Societies,  September,  1915,  p.  313. 

2  Conveniently  found  in  Journal  of  the  Allied  Societies,  December,  1917 


250 


MnTal  cariMS 


per  milligram  before  a  meal  and  100,000,000  after  the  meal.     This 
would  correspond  with  a  priori  assumptions. 

Howe^  in  an  extensive  study  upon  the  flora  in  cavities  in  the  first 
and  second  molars  of  children  pursued  the  plan  of  sealing  the  caries 
fungi  in  the  cavities  with  filling  without  antiseptic  qualities  for  six  to 
twelve  weeks  (Class  I)  and  with  filling  with  slight  antiseptic  qualities 
for  a  much  shorter  period  (Class  II)  in  order  that  extraneous  bacteria 
not  essentially  involved  in  the  carious  process  might  die  or  be  killed 
out,  while  those  more  essentially  associated  might  thrive.  The 
contents  of  open  cavities  were  used  as  controls  (Class  III).  In  all 
three  classes  material  was  obtained  from  (1)  the  superficial,  (2)  the 
middle,  (3)  the  deep  laA'ers  of  affected  dentin  and  (4)  from  the 
apparently  unaffected  layer  beneath. 

Fig.  257 


k-^ 


h 


S^^Mik 


fe*- 


Bacillus  acidophilus.     Fortv-eight-hour  culture  on  glucose-agar. 

(Howe.) 


Gram  stain.      X  2000. 


Howe  describes  the  microorganisms  found  as  forming  (and  existing 
under)  high  degrees  of  acidity  (even  14  per  cent.)  and  states  that  this 
limits  the  number  concerned  to  few  as  other  organisms  do  not  with- 
stand such  acidity.  He  also  states  that  they  belong  to  the  Moro- 
Tissier  group  and  present  the  same  morphological  features  as  the 
bacteria  of  this  group  isolated  from  the  intestines  of  nurslings. 
Howe  describes  the  various  acidific  bacteria  found  as  follows : 
"The  organisms  constantly  found  in  dental  caries,  and  belonging 
as  we  believe  to  the  ]\Ioro-Tissier  group  because  of  their  highly 


1  Dental  Cosmos,  October,  1917. 


EXCITING  CAUSES  251 

aciduric  character,  we  have  called:  Bacillus  acidophilus  (Moro), 
Bacillus  X,  Bacillus  M,  Bacillus  Y,  Bacillus  bifidus. 

"Bacillus  acidophilus  of  ]\Ioro  as  found  in  dental  caries  is  a  non- 
motile,  non-pathogenic  rod.  When  grown  on  agar  it  is  short  and 
thick  and  measures  0.75  x  2  to  3  microns.     It  is  Gram-positive. 

"On  glucose-agar  the  rods  are  longer  and  thinner  and  more  dis- 
tinctly arranged  in  groups  with  the  individuals  showing  parallelism. 
They  produce  turbidity  of  the  media.  They  are  Gram-negative. 
On  blood  serum  the  rods  measure  0.1  x  1  microns.  They  are  Gram- 
negative,  grouped  as  in  glucose-agar. 

"Bacillus  acidophilus  grows  best  anaerobically  when  first  isolated 
by  means  of  acid  broth.  In  milk  it  clots  the  lower  portion  first. 
In  peptone  water  it  produces  no  indol  or  ammonia.  In  broth  it 
forms  a  heavy  sediment  with  some  tiu-bidity.  It  forms  no  gas  in 
sugar.  It  is  a  facultative  anaerobe  and  should  be  transplanted 
every  ten  days.  It  is  a  high  acid  former.  ]\Iost  strains  ferment 
saccharose,  glucose,  lactose,  maltose  and  rafEnose.  From  7  to  10 
c.c.  of  X/XaOH  is  required  to  neutrahze  100  c.c.  of  the  bouillon. 
It  does  not  ferment  lactose  as  readily.  According  to  the  studies  we 
have  made  it  is  not  as  pleomorphic  as  has  been  supposed.  The 
colonies  are  sHghtly  raised,  round,  smooth,  opaque  and  white, 

"Bacillus  X  is  somewhat  pleomorphic.  It  is  Gram-positive  on 
agar.  It  most  frequently  appears  as  a  long  chain  of  short,  thick 
rods,  5  X  0.5  microns,  the  chains  often  showing  parallelism.  Under 
certain  conditions  the  individuals  are  considerably  longer  and  do 
not  occur  in  chains.  Moreover,  smears  of  the  organism  often  show 
only  masses  of  long,  tangled,  unbroken  threads,  occasionally  having 
one  long  thickened  end.  On  glucose  agar  many  of  the  individuals 
fail  to  retain  the  Gram  stain.  It  is  an  anaerobe  facultatively  aerobic. 
It  produces  a  high  degree  of  acidity  often  requiring  14  c.c.  of  XVX^aOH 
to  neutralize  100  c.c.  of  the  bouillon.  It  ferments  glucose,  saccharose 
and  levulose,  but  does  not  ferment  lactose  readily.  It  coagulates 
milk  and  does  not  form  indol  or  ammonia. 

"On  petri  dishes  its  colonies  are  transparent,  round,  entire,  slightly 
raised. 

"Bacillus  M  is  a  small,  slightly  curved  rod,  Gram-positive  on 
agar.  Gram-negative  on  glucose  agar  and  blood  serum.  In  smears 
the  organisms  appear  as  bent  individuals,  in  pairs,  with  concave 
sides  facing  each  other,  and  in  clusters,  sometimes  joined  end  to 
end  and  thus  forming  sectors  of  a  circle.  It  possesses  the  same  high, 
acid-forming  properties  as  does  Bacillus  X.  It  grows  best  on  glucose 
agar,  on  which  it  forms  small,  round,  convex,  cream-white  to  brownish 
colonies,  the  pigment  increasing  with  age. 


252 


DENTAL  CARIES 


"Bacillus  Y  is  a  straight  or  slightly  curved  rod  with  rounded  and 
sometimes  tapering  ends.     It  measures  from  1  to  2  microns  x  0.2  of  a 


Fig.  258 


-%!^^ 

S^^^S^mlk 

'^^ 

i 

^^-■ 

.^^^^ 

c- 

■J^IK^^B^ 

w 

'wSflBt^'' 

;. 

tW^x- 

Bacillus  M.    Forty-eight-hour  culture  on  glucose-agar.     Gram  stain.     X  2000.    (Howe.} 

micron.     The  cells  are  arranged  side  by  side.     It  is  Gram-positive 
on  agar  and  on  glucose. 

Fig.  259 


Bacillus  Y.    Seventy-four-hour  culture  on  glucose-agar.    Gram  stain.     X  2000.    (Howe.) 

"On  blood  serum  it  occurs  in  the  form  of  rods  3  to  6  microns  long, 
and  as  long,  winding  threads  with  a  width  of  0.5  of  a  micron.     The 


EXCITING  CAUSES 


253 


ends  are  frequently  thickened.  Both  rods  and  threads  are  Gram- 
negative  and  may  contain  one  or  more  Gram-positive  bodies. 

"This  microorganism  we  have  found  but  one  or  two  times.  We 
have  reserved  it  for  future  study. 

"B.  bifidus,  as  it  appears  in  the  carious  tooth,  is  to  be  found  in 
many  forms.  It  is  found  frequently  in  its  bifiu-cating  state  with 
tapering  or  with  thickened  ends,  in  V  and  Y  forms,  in  streptococcal 
forms,  as  masses  of  Gram-negative  cocci,  as  straight  rods,  in  crosses 
and  as  a  spore-former.  It  is  Gram-positive  in  young  cultures.  It 
grows  aerobically  and  anaerobically,  although  according  to  Kendall 
it  is  a  strict  anaerobe.  Noguchi  shows  it  to  have  both  anaerobic 
and  aerobic  phases.  In  contradistinction  to  his,  the  bifurcating  form 
of  our  organism  grows  well  aerobically  after  adaptation  to  artificial 
media.     The  colony  is  raised,  white,  entire,  butyrous." 


Fig.  260 


One  form  of  Bacillus  bifidxis. 


Forty-eight-hour  culttiTe  on  blood-serum. 
X  2000.     (Howe.) 


Gram  stain. 


It  is  quite  clear  that  bacteria  are  the  exciting  causes  of  dental  caries; 
and  that  for  their  function  as  such  they  require  carbohydrate  material 
as  food.  It  is  probably  true  that  in  order  to  act,  the  acid-producing 
bacteria  must  be  attached  to  the  teeth  in  the  form  of  plaques  (to  be 
later  described),  or  the  food  and  bacteria  as  a  mass  must  be  attached 
at  some  undisturbed  location. 

The  action  of  bacteria  upon  these  substances  has  been  studied.  The 
carbohydrates  introduced  into  the  mouth  as  food  are  monosac- 
charids,  disaccharids,  and  polysaccharids.  (1)  The  monosaccharids 
or  glucoses  have  the  general  formula  CeHiaOe,  and  are  represented  by 


254  DENTAL  CARIES 

dextrose  and  levulose,  found  in  seeds,  fruits,  roots,  honey,  and  in 
many  forms  of  candy,  such  as  peanut  brittle  and  glaces,  and  galac- 
tose formed  from  lactose  or  milk  sugar  by  hydrolysis.  These  ferment 
directly  into  lactic  acid  without  formation  of  gas. 

C6H12O6  +  bacterial  enzyme  =  2C3H6O3. 

A  certain  proportion  of  the  glucose,  etc.,  is  appropriated  by  the 
bacteria  as  food.  (2)  Disaccharids  or  saccharoses  have  the  general 
formula  C12H22O11.  The  principal  one  is  saccharose,  found  in  sugar- 
cane, the  sugar-beet,  sugar-maple,  and  maize.  This  is  inverted  by 
the  inverting  ferment  of  the  bacteria  into  glucose  and  levulose  through 
a  process  of  hydration: 

C12H22O11  +  H2O  +  bacterial  enzyme  =  C6H12O6  =  C6H12O6. 

Cane  sugar       Water  Glucose  Levulose 

Two  other  disaccharids  enter  the  mouth  or  are  formed  therein: 
lactose  and  maltose,  both  C12H22OU  (H2O).  Lactose  exists  in  milk, 
and  by  hydrolysis  is  changed  by  bacteria  to  galactose,  2C6H12O6,  and 
then  ferments  like  other  monosaccharids.  Maltose  is  an  intermediate 
product  in  the  formation  of  glucose  from  starch,  and  is  produced  by 
the  action  of  ptyalin.  It  is  readily  fermentable  by  yeast  and  by 
some  mouth  bacteria  (Goadby).  (3)  Polysaccharids  or  amyloses 
with  the  general  formula  (C6Hio05)n.  Starch,  cellulose,  glycogen,  and 
gum. 

Starch  was  found  by  Miller^  not  to  undergo  direct  fermentation  by 
mouth  bacteria — i.  e.,  culture  media  containing  starch,  but  not 
sugar,  when  infected  by  bacteria  did  not  ferment  into  lactic  acid 
unless  ptyalin  was  present.  When  saliva  was  used,  however,  the 
acid  reaction  occurred,  owing  to  the  formation  of  glucose  through  the 
action  of  ptyalin. 

In  oral  fermentation  starch  is  first  changed  by  ptyalin  to  maltose 
by  hydration,  and  the  maltose  to  glucose.  Then  the  bacteria  change 
this  to  lactic  acid. 

2C6H10O6  +  2H2O  +  ptyalin  =  C12H22O11  (H2O) . 
Starch.         Water.  Maltose. 

Erythrodextrin  and  achrodextrin  are  intermediate  products. 

Ci2H220ii(H20)  +  ptyalin  =  2C6H12O6. 
Maltose,     or  bacterial  enzyme. 

2C6H12O6  +  bacterial  enzyme  =  4C3H6O3. 

According  to  Goadby^  a  few  bacteria  found  in  the  mouth  can  pro- 
duce the  change  direct  from  starch  to  maltose  and  thence  to  acid. 
This  is  of  no  practical  consequence,  however,  as  ptyalin  is  always 
present  in  the  mouth.     (See  Miller  above.) 

Glycogen,  CeHioOs,  or  animal  starch,  is  fermented  to  glucose  by  liver 

1  Microorganisms  of  the  Human  Mouth.  2  Mycology  of  the  Mouth. 


EXCITING  CAUSES  255 

cell  ferment.  Michaels  and  Kirk  claimed  a  glycogenic  principle  to  exist 
in  saliva  which  could  be  a  food  for  the  bacteria  (see  pages  255-269). 
Miller  has  demonstrated  that  bacteria  produce  acid  from  starches 
and  sugars  in  about  equal  proportions,  provided  the  starches  are 
cooked.  The  cooking  of  starchy  foods  bursts  the  starch  granules 
and  renders  them  more  adhesive  to  the  teeth,  as  well  as  more  fer- 
mentable. The  following  synopsis  of  experiments^  made  with  food 
mixed  with  saliva  in  definite  quantities  speaks  for  itself: 

Duration  of 
Material.  experiment.  Acida  formed  in  units. - 

Bread,  starch,    potato,   macaroni, 

rice,    corn,    and    other    cooked 

starches 12  and  30  hours.  20  to  25  and  42  to  110 

Raw  starches,  potato,  spinach,  etc.  12  and  30  hours.  0  0 

Cane-sugar  and  grape-sugar       .  12  and  30  hours.  17  to  20  and  37  to  41 

Meats,  fish,  eggs,  etc.      ...  12  and  30  hours.  0  or  alkaline. 

The  table  shows  that  albuminous  materials  and  raw  starches 
produce  no  acid  and  are  not  concerned  in  caries  except  in  so  far  as 
meats,  etc.,  act  as  culture  media  perpetuating  bacteria,  which  later 
may  produce  an  acid  reaction  in  carbohydrate  materials. 

Milk  contains  a  carbohydrate  (lactose)  and  often  lactic  acid  bacilli. 
It  therefore  may  supply  both  the  bacilli  and  their  food.  This, 
however,  has  relation  to  caries  only  after  plaque  formation,  or  by 
retention  of  acid  milk  against  the  teeth.  That  such  a  result  may 
occur  has  been  shown  by  Bennett. 

PickerilP  tested  the  acid-forming  powers  of  foodstuffs,  chewed,  and 
incubated  for  four  days.    The  following  table  resulted: 

Acid  units  each 
neutralizing  c.c.  of  N/5 
Food  material.  NaOH. 

Pastry 5.2 

White  bread 4.4 

Toast 4.4 

Brown  bread 3.6 

Chocolate 3.6 

Biscuit  - 3.5 

Apple 2.6 

Potato 2.5 

Bread  and  butter  with  jam 2.5 

Crust  of  bread 2.0 

Parsnip 1.7 

Orange 1.2 

Salad 1.1 

Cane-sugar 0.9 

Rice 0.9 

Meat  (alkaline  to  acid  unit  N/5H2SO4)      ....     4.8  alkaline 

1  Microorganisms  of  the  Human  Mouth. 

2  An  acid  unit  equals  the  amount  of  acid  necessarj^  to  neutralize  an  alkaline  unit,  i.  e., 
0.1  c.c.  of  a  0.5  per  cent,  solution  of  potassium  hydrate — e.  g.,  if  in  a  quantity  of  acid 
material  containing  an  unknown  amount  of  acid,  25  of  such  alkaline  units  are  neces- 
sary to  neutralize  the  reaction,  there  were  25  acid  units  present  in  It.  For  pxirpose  of  com- 
parison the  quantities  of  material  used  were  4.0  c.c.  of  saliva  and  0.5  grams  of  the  food. 

5  The  Prevention  of  Dental  Caries  and  Oral  Sepsis, 


256  DENTAL  CARIES 

He  calls  attention  to  the  various  factors  of  viscosity  of  saliva, 
natural  adhesiveness  of  food  to  teeth,  etc.,  as  modifying  factors  in 
inception  of  caries. 

Dr.  Harold  Clark^  has  called  attention  to  the  fact  that  the  English, 
whose  teeth  are  much  subject  to  caries,  consume  chocolate  in  large 
quantities.  The  observation  of  Dr.  Albert  King  below  regarding 
white  bread  seems  partly  confirmed. 

The  fats  may  be  fermented  with  production  of  fatty  acids.  Goadby 
has  found  these  of  no  importance  in  relation  to  caries,  but  Miller  has 
shown  that  the  acids  found  in  dermoid  cysts,  among  which  are  fatty 
acids,  can  produce  decalcification;  as  other  acids  were  present,  the 
relation  of  fatty  acids  is  not  quite  clear.  Miller  asserts  that  fats 
deposited  upon  the  teeth,  as  well  as  calculus  retard  decay,  and  that 
fat  mixed  with  saliva  will  give  an  alkaHne  reaction^ 

That  alkalies  do  not  produce  tooth  disintegration  in  the  mouth  is 
shown  by  the  fact  that  a  tooth  is  not  affected  by  alkaline  solutions, 
which  are  not  strong  enough  to  injure  the  soft  parts. 

The  influence  of  carbohydrate  diet  in  the  production  of  caries  is 
well  shown  by  tables  compiled  by  Mummery  and  quoted  by  Miller.^ 
The  races  consuming  a  fish  and  meat  diet  almost  exclusively — e.  g., 
the  Esquimaux — are  recorded  as  having  about  3  per  cent,  of  caries 
in  skulls  examined,  while  those  using  a  mixed  or  vegetable  diet  have 
from  10  to  40  per  cent,  of  caries.  A  most  convincing  example  is 
that  given  by  Miller  of  two  related  tribes  living  on  either  side  of 
the  Andes,  in  the  Argentine  Republic,  and  Chili  respectively.  The 
former,  a  cattle  breeding  and  meat  eating  tribe,  were  practically  free 
from  caries,  while  the  latter,  living  on  mixed  foods,  and  consuming 
sugar,  had  19  per  cent,  of  caries.  Miller  and  others  have  shown  that 
millers  and  confectioners  rapidly  develop  caries  after  engaging  in 
the  occupation,  probably  owing  to  the  inhalation  of  flour  and  sugar 
dust.  Albert  B.  King*  has  recorded  observations  upon  132  cases  of 
bread  eaters,  finding  that  87  who  used  bakers'  bread  exclusively  had 
much  caries,  31  who  used  alternately  bakers'  and  home-made  bread 
had  a  less  prevalence,  while  the  14  using  home-made  bread  exclusively 
had  only  six  cavities  in  three  years.  The  results  are  certainly  worthy 
of  attention  and  of  further  observations.  I.  L.  Porter^  suggests  that 
the  glutein  in  the  flour  used  in  baker's  bread  causes  adhesion  of  the 
masses  to  the  teeth. 

While  the  fermentation  of  carbohydrate  food  debris  into  acid  is 
conceded  to  be  the  active  exciting  cause  of  dental  caries,  the  modus 

'  Private  communication.  ^  Dental  Cosmos,  1904. 

3  Microorganisms  of  the  Human  Mouth.  *  Dental  Cosmos,  1905. 

5  Dental  Digest,  1914,  p.  147. 


EXCITING  CAUSES  257 

operandi  of  the  inception  has  not  been  satisfactorily  settled.  Miller 
held  that  as  he  was  able  to  find  bacterial  plaques  upon  many  sur- 
faces of  teeth,  even  in  the  mouths  of  immunes,  without  caries  beneath, 
the  plaques  had  no  relation  to  the  inception  of  caries  of  enamel,  but 
that  the  carbohydrate  food  collecting  at  favoring  spots  undergoes 
acid  fermentation,  with  production  of  enamel  decalcification,  after 
which  the  bacteria  enter.  By  experiments,  he  determined  that  the 
plaques  rather  hindered  the  action  of  acids  experimentally  used  as  a 
decalcifying  agent.  Black,  on  the  other  hand,  claims  that  the  bacteria 
produce  a  gelatinoid  material  and  are  left  upon  the  teeth  in  the 
form  of  a  plaque  or  zooglea  mass,  and  that  the  plaque  is  a  thin, 
transparent,  slightly  yellowish  film,  not  seen  without  close  inspection. 
(It  can  be  stained  by  iodin. — Editor.)  Williams  found  a  film  of 
bacteria  over  the  decalcified  area  in  almost  all  cases  of  superficial 
caries  of  enamel,  and  that  it  has  sufficient  resistance  to  permit 
grinding  in  situ  (Figs.  276  and  277). 

Goadby  frequently  found  on  the  opaque  white  patches  of  softened 
enamel,  a  coccus  to  which  Williams  called  attention,  which  would 
cause  a  plaque  deposition  upon  teeth  suspended  in  its  culture,  and 
that  when  acid-producing  bacteria  were  mixed  with  the  coccus  and  a 
carbohydrate  mediima  used,  superficial  decalcification  of  the  enamel 
under  the  plaques  was  produced  in  from  a  week  to  ten  days. 

Miller  also  showed  that  in  the  immune  with  unclean  teeth,  the 
putrefactive  reaction  was  the  dominant  one,  and  that  the  collection, 
if  persistent,  could  act  as  a  protective  against  the  access  of  acid- 
producing  material. 

In  the  above  data  we  find  that  the  plaques  are  almost  universal, 
even  on  immune  surfaces  (Miller),  so  that  their  presence  on  a  decal- 
cifying surface  is  probably  true,  as  claimed  by  Williams.  If,  then, 
they  are  a  protection  against  the  acids  produced  from  carbohydrate 
they  should  protect,  but  they  do  not.  Secondly,  experiments  with 
formed  acids  are  not  conclusive,  as  they  may  be  germicidal  and 
the  dead  film  might  be  a  relative  protection  against  decalcification 
by  the  acids.  Thirdly,  the  bacterial  films,  if  containing  acid-pro- 
ducing bacteria,  can  easily  take  up  any  carbohydrate  food  collected 
against  them,  form  acid  from  it,  which  they  then  pass  to  the  enamel 
in  a  nascent  state,  hold  it  against  it,  and  permit  it  to  abstract  the 
calcium  salts,  which  they  then  pass  out  as  lactates,  etc.,  or  allow  to 
remain  in  situ.  This  latter  conclusion  in  the  main  is  the  theory  of 
Black,  and  while  the  decalcifying  ability  of  infected  carbohydrate 
food  without  the  intervention  of  a  definite  previously  formed  plaque 
(but  possibly  by  a  self-formed  one)  is  a  possibility,  it  seems  a  reason- 
able conclusion  to  admit  the  activity  of  the  plaques.  Kirk  has  shown 
17 


258  DENTAL  CARIES 

that  the  precipitation  of  mucic  acid  from  sahva  rich  in  mucin  content, 
by  lactic  acid  produced  by  lactic  acid  bacilli,  plays  a  part  in  the 
development  of  the  plaques,  or  by  binding  the  bacteria  together 
creates  a  bacterial  plaque.  Von  Beiist^  has  shown  that  within  three 
hours,  a  mucinous  deposit  containing  many  colonies  of  bacteria  which 
rapidly  increase  in  size,  may  be  formed.  He  attributes  to  bacteria, 
a  large  share  in  the  formation  of  calculus  which  is  the  theme  of  his 
paper,  but  it  also  throws  light  on  caries  plaques. 

The  frequent  disturbance  of  the  plaques  by  monthly  cleansings 
(prophylaxis),  also  prevents  dental  caries  in  large  degree,  so  that  they 
must  have  some  relation  to  the  inception,  though  it  is  only  fair  to 
state  that  a  constant  warfare  against  any  species  of  bacteria  doubtless 
vastly  reduces  their  number  in  the  mouth. 

Noyes"^  claims  that  in  w^ell-cared-for  mouths  the  confinement  of 
acid  under  the  plaques  is  great,  while  in  uncared-for  mouths,  though 
much  acid  is  formed,  it  may  be  dissipated  in  the  saliva  and  the  teeth 
not  be  much  attacked.  This  argument,  however,  does  not  take  into 
consideration  the  idea  of  Miller,  that  stagnant  materials  take  on  a 
putrefactive  reaction  after  the  acid  production  is  exhausted  (see 
p.  271). 

The  Predisposing  Causes  of  Caries. — The  causes  of  the  predis- 
position to  caries  are  local  and  general. 

Local  Predisposing  Causes. — So  invariably  does  caries  begin  in 
sulci  or  pits  upon  approximal  surfaces,  about  defective  fillings,  and 
upon  unclean  surfaces,  that  faults  of  form  or  retentive  nature  of 
approximation,  defects,  and  faulty  position  of  the  teeth  must  bear  a 
relation  to  the  difficulty  of  keeping  the  parts  free  from  accumulations 
of  bacteria  and  carbohydrates. 

These  local  predisposing  causes,  as  they  are  called,  are  simply 
conditions  favoring  the  formation  of  the  bacterial  plaques  upon  the 
teeth  and  the  retention  of  carbohydrate  food. 

Lack  of  Oral  Hygiene. — This  is  perhaps  the  most  frequent  local 
predisponent  of  caries.  It  is,  in  fact,  a  factor  in  the  exciting  cause 
and  its  reverse  is  prophylaxis.  Most  people  either  can  not  or  will 
not  cleanse  the  teeth  thoroughly,  hence  their  lack  of  care  predisposes 
them  to  caries.  It  may  not  occur,  but  is  liable  to  do  so.  Otherwise 
lack  of  hygiene  means  the  presence  of  microbic  plaques  and  carbo- 
hydrate food,  and  these  are  exciting  causes  of  caries. 

Faults  of  Form. — Deep  pits  or  sulci  in  the  occlusal  surfaces  of 
bicuspids  or  the  occlusal  or  buccal  surfaces  of  molars,  or  in  the  lingual 
surfaces  of  incisors,  and  occasionally  cuspids,  or  pits  upon  the  cusps 

1  Items  of  Interest  June,  1912.  2  jbid.,  1909.  p.  750. 


PREDISPOSING  CAUSES  259 

of  bicuspids  or  molars,  or  in  other  unusual  situations,  are  not  sub- 
jected to  a  cleansing  friction,  and  so  permit  bacteria  to  form  plaques 
in  these  locations  (Figs.  262  to  275). 

The  nature  of  the  approximal  contact  has  to  do  with  the  inception 
of  caries.  Teeth  are  seen  in  which  the  approximal  surfaces  are  well 
rounded  and  their  buccal  and  lingual  angles  free  from  approximation. 
Such  teeth  are  usually  relatively  narrow  at  their  cervices,  so  that 
these  also  recede  well  from  the  line  of  contact.  A  V-shaped  space 
is  formed,  which  the  gum  festoon  normally  nearly  fills.  Such  per- 
fection of  contour  is  also,  as  a  rule,  associated  with  a  perfect  organi- 
zation of  the  enamel  structure,  in  virtue  of  which  the  surface  is 
smooth.  While  such  teeth  may  decay  approximally,  there  is  much 
less  tendency  to  caries  (Figs.  278  and  284). 

Opposed  to  this,  approximations  exist  of  a  broad  nature.  Broad 
approximations  are  very  common,  and  not  infrequently  are  asso- 
ciated with  a  certain  degree  of  enamel  opacity  and  an  unevenness 
of  enamel  surface  plainly  visible  to  the  naked  eye  (see  page  148). 

The  fluid  exuded  by  the  gum  is  normally  alkaline  in  character, 
and  probably  neutralizes  the  products  of  acid  fermentation.  ^Nlendel^ 
has  shown  that  the  gingival  exudate  contains  large  nimibers  of  phago- 
cytes. In  view  of  this  fact,  the  first-mentioned  form  of  contact  evi- 
dently affords  more  of  this  immunizing  principle.  The  extension  of 
cavity  margins  beneath  the  gum  has  been  strongly  indicated  by 
experience  as  good  practice,  and  probably  is  explainable  upon  this 
ground  and  by  phagocytosis  as  there  is  evidence  that  the  gum  has 
some  such  action  upon  metal  placed  beneath  it,  as  it  is  noted  that 
when  unclean  gold  crowns  are  removed  the  portion  extending  beneath 
the  gmn  is  usually  quite  clean. 

With  the  narrow  approximations,  saliva  is  readily  forced  between 
the  teeth  and  neutralizes  the  acids  formed,  or  washes  away  soluble 
carbohj^drates,  the  food  for  the  bacteria.  With  the  broad  approxima- 
tions such  a  result  is  less  likely  to  occur. 

Stagnant  saliva  retaining  carbohydrates,  probably  will  develop  an 
acid  reaction.    (Miller.) 

A  depressed  approximal  surface  may  decay,  but  frequently  does 
not.    An  acquired  fault  of  form  requires  notice. 

Anatomically,  the  gum  covers  the  cementum  and  the  enamel 
margin.  When  recession  of  the  gum  occurs,  the  cementum  is  left 
exposed  and  food  debris  accumulates  at  the  angle  formed  by  it  with 
the  gum.  Owing  to  the  cementum  being  less  smooth  than  enamel, 
microbic  plaques  readily  collect,   hence  decay   of  the   cementum 

1  Anali  di  Stomatologia,  1917;  See  Cosmos,  1917,  p.  760. 


260  DENTAL  CARIES 

frequently  occurs,  and  is  apt  to  progress  rapidly,  owing  to  the 
natural  low  percentage  of  inorganic  matter  (Figs.  268,  302,  and  303). 

Wachsler^  has  called  attention  to  symmetry  in  caries,  i.  e.,  in  like 
locations  on  opposite  sides  of  the  mouth.  He  attributes  this  to  irri- 
tation of  trophic  centers  thi'ough  a  reflex,  while  Horrowitz^  antago- 
nizes this  view,  considering  it  due  to  symmetric  local  predisposing 
causes  (malformations  or  peculiarities  of  structure  form  approxima- 
tion,  etc.)  inviting  hke  inceptions. 

Arrangement  and  Position  of  the  Teeth. — The  overlapping 
of  one  tooth  upon  another  creates  a  form  of  contact,  producing  a 
tendency  to  decay  at  that  point.  Angle^  claims  to  have  observed  a 
comparative  freedom  from  caries  of  very  irregular  teeth  (Fig.  275). 

The  presence  of  a  supernumerary  third  molar,  lying  at  the  buccal 
side  of  the  interdental  space,  between  the  second  and  third  upper 
molar,  or  an  inlocked  bicuspid,  very  frequently  causes  approximal 
caries  at  the  contact  points.  The  upper  third  and  lower  third  molars 
frequently  stand  in  bad  relation  to  the  cheek  or  the  gum. 

Food  collects  upon  their  buccal  surfaces,  or  they  are  not  subjected 
to  the  friction  of  the  tooth-brush,  and  decalcification  of  a  broad  area 
of  a  buccal  surface  frequently  results. 

Defects  about  Fillings. — Under  the  caption  of  Recurrence  of 
Caries,  will  be  found  a  list  of  the  causes  which  perpetuate  caries  about 
fillings.  Defectively  cemented  bands  are  also  a  cause.  I  believe 
the  abundance  of  these  and  a  lack  of  oral  hygiene  to  be,  in  a  large 
degree,  the  measure  of  a  tendency  to  persistent  caries.  A  patient 
has  a  large  number  of  cavities  due  to  a  period  of  negligence,  with 
consequent  intensity  of  oral  fermentation.  If  these  are  obliterated 
in  the  best  manner  with  physically  perfect  fillings,  and  oral  hygiene 
be  exact,  the  tendency  to  caries  is  largely  obhterated.  If,  on  the 
other  hand,  a  large  number  of  even  slightly  defective  fillings  are 
made,  not  only  is  recurrent  caries  induced,  but  the  caries  ferment  is 
continuously  active,  and  exact  oral  hygiene  is  an  impossibility.  The 
number  of  cleansings  a  day  is  no  guarantee  of  perfect  hygiene,  even 
with  perfect  teeth,  as  nothing  is  more  common  than  to  see  unclean 
embrasures  easily  taking  the  stain  of  tincture  of  iodin  even  in  the 
anterior  part  of  the  mouth  (in  less  degree  than  shown  in  Fig.  261). 
Unquestionably,  food  debris  may  even  be  swept  into  the  interdental 
spaces  by  brushing  alone.  Miller^  has  shown  that  a  mixture  of  bread 
and  saliva  may  become  decidedly  acid  in  one  hour,  and  superficially 
decalcify  sections  of  dentin  in  five  hours.  With  this  going  on,  day 
after  day,  in  cases  of  soluble  teeth  and  without  other  aid  than 

1  Dental  Cosmos,  March,  1915.  ^  ibid.,  June,  1915. 

3  Ibid.,  1903.  4  Ibid.,  1905. 


PREDISPOSING  CAUSES 


261 


brushing,  and  often  this  not  thoroughly  done,  the  persistence  of 
decay  is  not  surprising.  This,  however,  does  not  prove  the  absence 
of  systemic  susceptibility  or  immunity,  as  an  added  cause  of  caries 
or  its  absence,  A  condition  similar  to  a  defect  about  a  filling,  is 
that  of  the  presence  of  an  orthodontic  appliance  which  may  afford 
convenient  nooks  for  caries  fungi,  and  food.  In  the  use  of  base 
metal  wires  about  teeth  for  pyorrhea,  the  wire  either  has  some  anti- 
septic, action  probably  due  to  the  contained  copper,  or  the  pyorrhetic 
condition  itself  furnishes  an  alkaline  element.  In  such  case  caries 
frequently  does  not  occur. 

Fig.  261 


Caries  of  enamel  about  the  cervices  of  many  teeth,  due  to  tenacious  films  collected 
upon  them;  at  first  probably  neglected,  later  impossible  to  cleanse  with  brush  alone. 
(Model  by  W.  A.  Capon.)  Fairly  clean  teeth  stained  with  iodin  present  such  an  appear- 
ance.    (See  prophylaxis.) 


Structure. — While  the  structure  of  the  enamel  has  no  relation  to 
the  inception  of  caries,  that  is,  teeth  of  poor  structure  may  not 
decay,  a  roughness  of  the  enamel  surface,  which  often  accompanies 
teeth  of  opaque  appearance,  may  act  as  a  favoring  condition, 
and  after  inception  of  caries,  inferior  structure  and  possibly  the 
presence  of  Caush's  tubes  may  permit  more  rapid  disintegration. 
(See  p.  145.)^  An  interesting  examination  of  16,000  mouths,  made  in 
Sweden  by  Forberg  (Stockholm),  and  others  by  Rose  in  Baden  and 
Thuringia  seems  to  show  that  there  is  a  relation  between  the  color 
(structure)  of  teeth  and  the  presence  of  caries,  the  following  averages 

1  This  statement  now  made  in  two  editions  has  been  further  experimentally  con- 
firmed by  PickerUl  (The  Prevention  of  Dental  Caries  and  Oral  Sepsis,  2nd  Ed.),  who 
has  shown  by  rubbing  graphite  upon  the  surface,  what  he  terms  "imbrication  lines," 
which  are  associated  with  "calcarine"  fissures  in  some  teeth.  Those  teeth  which 
contain  many  of  the  lines  and  fissures  are  termed  "malacotic, "  while  those  but 
slightly  imbricated  are  termed  "sclerotic."  By  test,  "malacotic"  teeth  were  found 
more  soluble  in  lactic  acid  solutions  than  the  sclerotic  (Ibid.,  p.  129).  A  similar 
result  was  obtained  with  hydrochloric  acid.  Malacotic  and  sclerotic  teeth  were  both 
but  little  affected  after  insertion  into  an  orange  for  a  week  but  the  malacotic  were  more 
affected  (Ibid.,  p.  130).  This  fact  is  of  importance  in  prophylaxis  (which  see).  Carbon 
dioxid  in  strong  solution  was  found  to   have  no  effect  upon  teeth  (Ibid,  p.  133). 


262  DENTAL  CARIES 

of  all  ages  being  observed:  White  teeth,  14.3  per  cent,  of  caries; 
yellowish-white,  16.4  per  cent.;  yellow,  20  per  cent.;  grayish  blue, 
24.3  per  cent. 

According  to  these  observers,^  in  the  regions  in  which  the  water 
was  rich  in  calcium  salts  the  individuals  examined  had  the  yellowish- 
white  teeth. 

Yamagishe-  observes  that  he  has  found  clinically  considerably  more 
decay  in  the  teeth  of  patients  with  light  hair  and  that  extracted  teeth 
from  light  haired  patients  decalcify  more  in  dilute  hydrochloric  acid 
than  the  extracted  teeth  of  dark  haired  patients.  The  "brownin" 
of  Black  may  have  some  relation  to  this  (see  page  156). 

Gautier^  has  found  that  in  young  pigs,  deficient  osseous  development 
corresponded  exactly  to  the  lack  of  calcium  salts  in  their  drinking 
water. 

McKay^  in  investigating  mottled  enamel  found  that  poor  quality 
of  enamel  occm-s  in  locaHties  the  water  of  which  shows  highest  lime 
content  and  equally  poor  enamel  in  localities  having  water  of  low 
calcium  content. 

Black^  made  analyses  of  so-called  hard  and  soft  teeth,  and  deduced 
from  them  the  opinion  that  the  hardness  and  softness  of  teeth  have 
nothing  to  do  with  the  inception  of  caries. 

Touching  this  point,  Black^  instances  the  case  of  a  man  whose 
enamel  had  always  been  chalky  and  as  easily  cut  as  a  slate-pencil, 
yet  who  had  little  caries  of  the  teeth.  That  some  teeth  of  apparently 
poor  structure  and  defective  form  do  not  decay  is  also  a  fact  of 
common  observation,  but,  as  a  rule,  they  go  together. 

Other  Local  Predisposing  Causes. — Acids  taken  in  excess  into 
the  mouth  may  act  as  predisponents  by  causing  a  roughness  of  the 
enamel,  which  invites  the  formation  of  the  bacterial  plaques.  A 
course  of  tincture  of  ferric  chlorid  has  a  bad  reputation  in  this  con- 
nection. In  the  cases  observed  by  the  editor,  the  hydrochloric  acid 
in  the  tincture  seemed  to  have  formed  roughnesses  between  the 
teeth,  and  many  large  cavities  of  not  unusual  form  were  later  pro- 
duced and  evidently  due  to  the  carious  process.  Weld,^  in  a  series 
of  experiments  to  determine  the  action  of  ferric  chlorid,  found  that 
the  pure  tincture  had  little  effect,  while  in  the  dilution  of  1:5  in  water 
it  had  much;  destroying  the  entire  enamel  in  twenty-four  hours. 
Head's  observations  on  the  effect  of  dilute  acids  are  in  general  accord 
with  this  principle  (see  page  216).    This  fact  indicates  the  prompt 

1  Dental  Cosmos,  1911.  2  ibid.,  1917,  p.  1008. 

3  L'Odontologie,  October,  1910.  See  Cosmos,  1911,  p.  242. 
*  Dental  Cosmos,  July,  1916,  p.  792.  ^  Ibid.,  1898.  ^  ibid. 

^  Quoted  by  Prentiss,  Dental  Cosmos,  September,  1912,  p.  1006. 


PREDISPOSING  CAUSES  263 

local  use  of  an  alkali  after  a  dose.  (See  Prophylaxis  of  Caries.) 
Howe^  claims  that  iron,  whether  as  chlorid  or  carbonate,  taken  in 
capsules,  returns  to  the  salivary  gland  for  excretion  as  ferric  chlorid 
and  may  exert  injurious  effects. 

Morjenstern^  describes  experiments  that  show  that  acid  iron  waters 
or  tinctures  have  a  decalcifying  action,  ferrous  iodid  and  ferric 
chlorid  being  particularly  injurious,  while  reduced  iron,  saccharated 
solution  of  iron,  and  albuminate  of  iron  produced  no  ill  effects  either 
local  or  through  systemic  action. 

The  acid  vomitus  of  pregnancy  and  seasickness  have  an  analogous 
effect.  It  is  not  likely,  however,  that  during  a  transatlantic  voyage 
large  cavities  can  develop.  The  probable  explanation  of  the  presence 
of  such  cavities  directly  after  the  voyage  is  that  they  existed  before 
the  voyage  was  begun.  Cavities  are  frequently  left  or  overlooked. 
(See  Prophylaxis  of  Caries.)  Since  the  advent  of  medication  by 
lactic  acid  preparations  and  those  containing  lactic  acid  bacilli,  such 
as  sour  milk,  analogous  effects  have  been  observed,  and  therefore  the 
mouth  should  be  washed  out  with  alkaline  antiseptics  after  such 
remedies  are  taken.^  ^ 

Miller  found  that  the  saliva  has  no  antiseptic  quality  as  a  whole 
and  contains  no  antiseptic  substance,  and  though  he  found  the  saliva 
of  immunes  to  develop  a  little  less  acid  than  that  of  highly  susceptible 
individuals,  the  difference  was  not  constant  and  not  sufficient  to 
account  for  the  marked  difference  in  susceptibility.  Miller  found  that 
carbohydrate  foodstuffs  mixed  with  an  alkaline  saliva  became  even 
more  acid  than  when  the  reaction  of  the  saliva  was  intensely  acid 
and  the  chance  for  caries  was  about  the  same  with  either  reaction 
at  the  start.  Goadby^  calls  attention  to  the  demonstration  of  Savarelli 
that  saliva  is  germicidal  for  small  quantities  of  bacteria  but  loses 
its  property  with  large  quantities.  This  may  have  some  bearing 
on  caries  prevention. 

Under  conditions  of  oral  irritation,  such  as  catarrhal  stomatitis, 
or  even  the  presence  of  many  cavities  of  decay,  a  stringy,  mucinous 
condition  of  the  saliva  may  result.  This  may  be  due  to  a  partial 
coagulation  of  the  mucin  by  the  acid  present  in  the  mouth,  and  the 
coagulum  may  entangle  food  masses  and  cause  their  adherence  to 
the  teeth. 

1  Dental  Cosmos,  January,   1913,  p.  39. 

«  Therapeutische  Monatshefte,  1908.  ^  Vanel,  Dental  Cosmos,  1904,  p.  694. 

*  I  had  a  patient  with  an  enormous  amount  of  caries.  He  had  used  buttermilk  daily 
for  a  year  or  two.  I  asked  him  to  stop  but  he  continued.  To  my  surprise  he  has  but 
little  new  caries  twelve  months  after  completion  of  his  large  line  of  work.  This  upset 
is  as  puzzUng  as  the  case  of  the  man  who  forms  calculus  freely  and  rapidly  though  prac- 
tically starv-ing  because  of  inability  to  swallow.     (See  Calculus.) 

'  Mycology  of  the  Mouth. 


264  DENTAL  CARIES 

Lack  of  Saliva  of  Alkaline  Potential. — Pickerill,i  in  exhaustive 
experiments,  shows  that  a  continuous  flow  of  saHva  may  be  reflexly 
excited  by  foodstuffs  having  taste  and  flavor,  and  especially  by 
organic  acids  of  fruit,  and  argues  that  such  alkaline  saliva  by  flowing 
over  teeth  neutralizes  any  acid  formed  by  fermentation.  Per  contra, 
its  absence  may  be  a  cause  of  caries.  The  argument  looks  rational, 
but  Pickerill  has  not  given  any  experiments  upon  susceptible  in- 
dividuals to  prove  his  case.  Marshall,-  as  the  results  of  experiments 
to  show  a  relation  between  carious  teeth  and  the  composition  of  the 
saliva,  offers  the  following  deduction:  "The  normal  resting  saliva 
of  persons  with  carious  teeth  is  characterized  by  (1)  a  relatively  high 
neutralizing  power  and  therefore  presumably,  (2)  a  high  content  of 
diffusible  substances,  (3)  a  low  content  of  proteins."  He  states  that 
the  neutralizing  power  of  resting  saliva  is  supernormal  while  that  of 
saliva  activated  by  chewing  paraffin  is  subnormal.  He  states  also 
that,  on  the  contrary,  activation  of  an  immune  to  caries  produces  a 
saliva  of  greater  neutralizing  power  than  that  of  the  normal  resting 
saliva,  and  having  a  considerably  lower  protein  content  and  higher 
content  of  inorganic  salts. 

Howe  and  Gies,  separately  working  in  this  field,  claim  that  there  is 
no  constant  relation  between  the  neutralizing  power  of  resting  and 
activated  saliva  and  the  incidence  of  dental  caries  while  admitting  its 
neutralizing  power.  That  is,  no  salivary  index  is  established,  as 
claimed  by  Marshall. 

Very  dry  mouths  (xerostomia)  have  a  viscid,  tenacious  saliva,  and 
usually  cervical  caries  is  present.  Some  individuals  are  greatly  incon- 
venienced and  may  have  to  frequently  moisten  the  mouth  to  obtain 
comfort. 

PickerilP  views  a  hyperdevelopment  of  the  nervous  system  as  Hable 
to  lead  to  sahvary  depression  through  cerebral  stimulation  and  states 
that  exacerbations  of  caries  occurs  in  certain  mouths  during  periods 
of  nervous  stress. 

The  contention  of  Lohmann  that  the  carbohydrate  element  in 
mucin  was  the  cause  of  caries.  Miller  examined  experimentally  and 
found  it  untenable,  but  that  the  explanation  here  given  of  its  entan- 
gling action  is  the  probable  one.  He  states  that  very  small  amounts 
of  lactic  acid  precipitate  the  mucin  and  thus  enable  the  bacteria  to 
become  fixed  to  the  teeth  as  plaques. 

Miller  has  noted  that  some  immunes  have  had  exceedingly  ropy 
saliva  which  could  be  drawn  out  into  long  threads,  while  much 

1  The  Prevention  of  Caries  and  Oral  Sepsis,  2d  Ed. 

2  Journal  of  Nat.  Dental  Assn.,  1917,  p.  782. 

3  British  Dental  Journal,  1915,  and  Cosmos,  June  15,  p.  715. 


PREDISPOSING  CAUSES  265 

caries  was  noted  in  the  mouths  of  some  almost  absolutely  free  from 
mucus. 

Miller  could  find  no  antiseptic  quality  in  the  saliva,  nor  any  prin- 
ciple corresponding  to  alexin,  and  found  that  bacteria  developed  in 
the  saliva  of  immunes  almost  as  readily  as  in  that  of  those  susceptible 
to  caries. 

He  also  pointed  out  that  the  mucus  may  readily  undergo  putre- 
factive fermentation  with  alkaline  reaction,  and,  again,  the  carbo- 
hydrates entangled  in  it  will  ferment  with  acid  reaction,  causing  any 
caries  which  might  be  attributable  to  mucin  fermentation.  Gies^ 
has  shown  that  salivary  mucin  forms  viscid  films  on  the  teeth,  which 
tend  to  thicken  by  accretion  and  in  which  millions  of  bacteria 
multiply,  particularly  at  night,  when  the  secretions  are  strongest. 

It  is  possible  that  the  secretion  from  the  gum  may  in  some  cases 
be  acid  and  favor  the  production  of  caries  by  decalcifying  the  enamel 
about  the  cervix  (Fig.  261). 

Cook  has  shown  that  glycogenic  infiltration  of  the  oral  mucous 
membrane  may  be  produced  by  the  use  of  irritant  or  astringent 
washes,  which  may  possibly  permit  a  change  of  this  substance  by 
bacteria  into  acid  about  the  necks  of  teeth,  accounting  for  a  certain 
form  of  cervical  decay  long  thought  to  be  due  to  an  acid  mucus. 

These  observations,  together  with  the  foregoing  data,  regarding 
the  inception  of  caries,  point  to  the  now  conceded  conclusion  that 
the  caries  of  teeth  is  entirely  due  to  the  environment  of  the  teeth, 
and  in  no  sense  does  it  arise  from  within  the  tooth,  and  that  in  so 
far  as  the  cause  is  active,  it  is  a  question  of  the  localization  of  the 
exciting  cause  or  its  factors  on  the  one  hand,  and  the  solubility  of 
the  teeth  on  the  other;  and  that  no  amount  of  cause  is  sufl&cient  to 
produce  it,  unless  permitted  to  exert  its  effect  upon  special  points 
upon  the  teeth;  in  other  words,  it  requires  localization  and  time  to 
act,  though  it  may  in  some  cases  be  broadly  localized. 

Systemic'  Predisposing  Causes. — Some  individuals  seem  to 
suffer  much  from  caries;  others  in  less  degree.  In  either  case,  periods 
of  immunity  or  comparative  immunity  may  be  established,  and  may 
be  again  follow^ed  by  a  period  of  susceptibility  and  a  succeeding 
immunity. 

Black  has  shown  that  caries  fungi  are  always  present  in  the  mouth, 
but  do  not  always  form  the  plaques.  Cases  also  exist  in  which  caries 
has  begun  during  some  period  of  susceptibility  and  a  number  of  new 
cavities  have  been  started.  Later  a  period  of  immunity  has  followed 
and  the  cavities  have  not  progressed. 

1  Journal  of  the  Allied  Societies,  June,  1912. 


266  DENTAL  CARIES 

These  facts  point  to  the  conclusion  that  a  period  of  caries  is  due  to 
one  of  the  following  causes:  (1)  The  bacteria  in  the  plaques  or  food 
are  of  an  active  acid-producing  kind  (or  in  immunity  they  are  not  of 
acid-producing  variety)  or  (2)  that  some  systemic  condition  changes 
the  constitution  of  the  oral  fluids,  permitting  the  formation  of  the 
microbic  plaques  upon  the  teeth,  or  (3)  increases  the  fermentation 
by  supplying  some  element  nutritive  to  bacteria  or  (4)  depriving  it 
of  some  element  inhibiting  the  growth  of  bacteria. 

So  far  as  classed,  systemic  conditions  influencing  susceptibility 
and  immunity  may  be  placed  under  the  four  headings:  Heredity, 
Prenatal  and  Postnatal  Influences,  Age,  and  Bodily  Condition. 

Heredity. — Black^  records  observations  on  certain  families  as 
showing  a  tendency  to  caries  of  certain  teeth  at  a  given  age,  or  in 
certain  positions  upon  the  teeth,  e.  g.,  occlusal  pits.  In  certain  cases 
the  hereditary  tendency  persists.  This  tendency  must  be  due  either 
to  an  inherited  cell  physiology,  or  diet  tendency  influencing  the  oral 
fluid,  or  to  transmitted  faults  of  form  or,  possibly,  of  structure  of 
the  teeth. 

Prenatal  and  Postnatal  Influences. — It  is  quite  probable  that 
the  systemic  condition  of  the  mother  during  gestation  may  pro- 
foundly modify  the  anatomicophysiological  condition  of  the  body 
ceUs  of  the  child;  nutritional  processes  may  suffer  and  the  postnatal 
tooth  development  proceed  irregularly,  structure  being  affected; 
moreover,  the  altered  biochemical  function  of  the  cells  may  stand 
in  close  relation  to  the  constitution  of  the  oral  fluids,  and  these  in 
turn  may  favor  the  development  of  caries  fungi.  If,  therefore,  the 
mother  is  not  properly  nourished,  the  teeth  may  not  be  well  con- 
structed, especially  if  lime  be  lacking  in  her  food.  The  same  line  of 
argument  may  be  applied  to  bottle  feeding  of  recently  born  infants, 
or  to  other  conditions  profoundly  affecting  general  nutrition.  In 
this  connection,  the  absence  of  the  influence  of  the  internal  secretion 
containing  hormones  which  should  be  transmitted  from  mother  to 
child  by  way  of  the  milk,  may  in  the  future  be  shown  to  have  a 
bearing  upon  cell  development  and  consequently  upon  the  product 
(as  the  enamel). 

In  an  examination  of  school  children,  Th.  Frick^  (Zurich)  found  a 
much  greater  percentage  of  decay  in  children  that  had  been  bottle- 
fed  at  between  three  and  six  months  of  age.  He  performed  an  experi- 
ment on  a  litter  of  six  dogs,  feeding  three  on  cows'  milk  and  bouillon; 
one  of  them  died,  and  the  others  had  poorly  developed  teeth.  The 
controls  were  normal. 

1  Dental  Cosmos,  1904.  2  Ibid..  1901. 


PREDISPOSING  CAUSES  267 

Breast  feeding  of  infant  is  important,  therefore  inasmuch  as  cows' 
milk  cannot  be  modified  to  exactly  meet  the  demands,  though  one 
often  may  discover  a  susceptible  who  was  artificially  fed,  yet  one  also 
finds  breast-fed  individuals  with  poor  teeth.  Rickets,  which  is  a  dis- 
ease due  to  improper  diet,  may  in  young  infants  have  a  like  effect 
upon  tooth  structure.^ 

Forberg  and  Rose^  have  shown  that  the  individuals  who  drink 
water  rich  in  calcium  salts  have  a  smaller  percentage  of  caries  than 
those  drinking  soft  waters.  Ferrier  has  observed  a  coincidence  of 
caries  and  the  drinking  of  boiled  water  which  had  been  deprived  of 
calcium  carbonate.  Whether  this  effect  is  due  to  a  better  develop- 
ment of  tooth  structure  or  is  a  post-developmental  effect  is  not  stated 
in  either  case.  The  point  brought  up  by  Head,^  who  has  shown 
the  apparent  rehardening  of  teeth  in  saliva  after  partial  decalcifica- 
tion by  a  weak  acid,  opens  up  the  question  here  as  to  whether  the  use 
of  calcareous  waters  after  tooth  eruption  can  increase  the  density  of 
enamel  or,  more  accurately,  fill  up  interstices  in  malacotic  teeth. 
Enamel  can  be  dried,  why  then  not  infiltrated  by  calcareous  solutions  ? 
The  question  cannot  now  be  answered,  though  Gies"*  has  shown  "  that 
water  passes  freely  back  and  forth  through  all  parts  including  the 
enamel  of  fully  developed  natural  extracted  teeth,"  and  "that  simple 
mineral  salts  and  common  organic  substances  such  as  cane-sugar 
similarly  diffuse."  Another  view  might  be  that  some  of  the  calcium 
salts  in  drinking  water  come  back  to  the  saliva  eventually,  and  if 
abundant  may  neutralize  the  acidity  in  plaques,  through  their  alka- 
linity, by  combining  with  the  acids  formed. 

Age. — That  the  age  has  an  influence  upon  caries  was  noted  by 
Flagg.  He  recorded  the  ages  from  five  to  eight,  twelve  to  twenty, 
thirty  to  thirty-five,  forty-five  to  fifty,  sixty  to  sixty-five  years,  and 
senility  as  periods  of  decay,  while  the  intervening  periods  were 
intervals  of  comparative  exemption. 

Black  has  noted  that  caries  is  a  disease  of  youth,  most  intense 
before  adult  age,  at  which  time  immunity  is  established,  provided  the 
teeth  have  been  well  and  promptly  filled  and  the  mouth  otherwise 
cared  for.  In  view  of  this  fact,  he  aimed  at  establishing  this  immunity 
by  close  attention  to  the  teeth  during  youth. 

He  records  fluctuations  in  susceptibility  not  unlike  those  recorded 
by  Flagg,  and  also  points  out  that  some  persons  pass  through  the 
ordinary  periods  of  susceptibility  and  first  develop  caries  in  middle 

1  Gies  and  his  collaborators  relate  interesting  though  not  conclusive  experiments  on 
this  subject  in  Journal  of  Allied  Societies,  March,  1916. 

2  Dental  Cosmos,  1899.  s  See  p.  216. 
^  See  Dental  Cosmos,  December,  1917,  p.  1240. 


268  DENTAL  CARIES 

age.  In  old  age,  general  recession  of  the  gum  is  common,  and  in  the 
conditions  of  debility  associated  with  old  age,  much  caries  of  cemen- 
tum  occurs.  The  patients  are  often  either  unwilling  or  unable  to 
keep  the  cementum  cleansed. 

Repeated  examinations  of  the  mouths  of  school-children  show  a 
deplorable  amount  of  caries  which  may,  perhaps,  be  attributable  to 
several  causes,  such  as  the  induction  of  a  lessened  systemic  resistance 
due  to  confinement,  study,  etc.,  and  also  to  the  inhalation  of  vitiated 
air,  which  presumably  also  contains  acid-producing  bacteria.  More- 
over, bacteria  of  caries  may  be  directly  transmitted  by  kissing, 
common  use  of  drinking  cups,  pencils,  etc.     Much  neglect  exists. 

Michaels,^  of  Paris,  has  observed  that  "the  saliva  of  adolescence 
contains  a  dextrinic  principle  (glycogen)  susceptible  of  fermentation 
under  the  influence  of  ptyalin  in  the  presence  of  earthy  salts.  Lactic 
acid  is  formed." 

Bodily  Condition. — It  is  a  matter  of  observation  that  such  con- 
ditions as  pregnancy,  typhoid  fever,  anemia,  leukemia,  diabetes, 
dyspepsia,  nervous  exhaustion,  and  debility  are  frequently  accom- 
panied by  or  followed  by  a  development  of  cavities  of  decay,  but 
whether  the  diseases  themselves  or  a  coincident  lack  of  oral  hygiene 
act  to  permit  the  formation  of  the  microbic  plaques  has  not  clearly 
been  made  out.  If  oral  and  dental  prophylaxis  be  practised  during 
these  conditions  and  convalescence  therefrom,  the  production  of 
cavities  is  much  limited,  but  this  does  not  prove  anything.^  The  same 
is  true  of  pregnancy,  which  introduces  an  exciting  cause  (the  vom- 
itus),  and  of  glycosuria,  which  may  introduce  glucose,  or  a  ferment- 
able substance  as  claimed  by  Michael,^  according  to  whom  it  takes 
a  red  coloration  with  Nessler's  reagent,  which  passes  into  a  grayish 
blue.  Black  contends  that  periods  of  susceptibility  are  noted  both 
in  apparent  good  and  ill  health.  That  apparent  health  may  really 
not  be  true  health  is  a  matter  that  must  be  considered. 

This  bodily  condition  is  seemingly  the  key  to  any  change  which 
can  occur  in  saliva,  or  mucus,  or  oral  phagocytosis,  to  one  of  which 
must  be  attributed  any  possible  systemic  effect  upon  caries  bacteria, 
which  can  aid  or  inhibit  their  growth  or  localization.  It  matters  very 
little  whether  the  bodily  condition  is  due  to  heredity  as  a  general 
modification  of  cell  physiology,  to  age,  or  some  period  of  stress,  as 


1  Sialosemeiology.    See  Dental  Cosmos,  1900. 

2  A  caries  susceptible  was  treated  after  pregnancy  and  during  lactation  for  many 
cavities.  The  value  of  prophylaxis  was  finally  so  impressed  upon  her  that  she  practised 
it  properly.  Since  then  she  has  had  typhoid  fever,  but  no  increase  in  caries;  which 
amounts  only  to  about  one  small  cavity  a  year ;  her  daughter,  aged  nine  years,  has  been 
treated  by  the  mother  and  has  never  needed  attention  beyond  occasional   examination. 

3  Quoted  by  Kirk,  see  Dental  Cosmos,  January,  1914,  p.  5. 


PREDISPOSING  CAUSES  269 

the  "change"  of  the  teeth,  puberty,  growth  during  adolescence, 
diet,  business  or  family  anxieties,  the  degenerative  tendencies  of 
advancing  age,  or  to  some  more  acute  systemic  condition,  as  typhoid 
fever,  diabetes,  etc.,  except  in  so  far  as  these  conditions  may  intro- 
duce into  the  oral  fluid  a  substance  which  may  act  either  (1)  as  a 
direct  decalcifying  agent  (an  acid)  or  (2)  as  an  indirect  decalcifying 
agent,  by  furnishing  a  food  material  for  the  bacteria  from  which  they 
may  manufacture  acid  (a  carbohydrate),  or  (3)  furnish  a  substance 
in  the  saliva  which  may  glue  the  germs  to  the  teeth,  or  (4)  take  from 
the  saliva  some  substance  which  normally  inhibits  plaque  formation. 

It  was  shown  under  the  caption  of  Erosion,  that  a  very  weak  acid 
may  decalcify  more  rapidly  than  a  stronger  solution,  and  it,  has 
been  noted  that  in  systemic  conditions  inducing  general  acidosis 
(as  chronic  nephritis  or  diabetes)  there  is  a  tendency  to  deep  decalci- 
fication of  cervices  of  teeth,  beginning  particularly  upon  the  cemen- 
tum.  While  by  no  means  proved  not  due  largely  to  fermentation  of 
carbohydrate  food  by  bacterial  plaques,  as  a  result  of  defective 
hygiene,  there  is,  nevertheless,  a  strong  suspicion  that  the  acidosis 
expressed  as  acidity  of  saliva  has  produced  the  decalcification.  There 
is  also  a  probable  reduction  in  the  amount  of  normal  sodium  phos- 
phates as  the  result  of  the  general  acidosis,  and  this  also  found  in 
the  saliva  reduces  the  controlling  quality,  which  Head  has  shown 
to  exist  when  a  certain  percentage  of  basic  sodium  phosphate  is 
present  in  solutions  having  an  acid  reaction.     (See  page  216.) 

Michaels^  states  that  the  constitution  of  the  saliva  changes  with 
the  establishment  of  various  diatheses,  and  that  a  physiological 
saliva  with  the  biochemical  principles  in  a  state  of  equilibrium  is 
probably  very  rare.  He  states  that  the  most  active  dental  caries  is 
found  in  the  mouths  of  hypo-acid  individuals,  in  whom  saline  chlorids 
predominate  over  the  acid  elements  of  metabolic  waste,  reducing  the 
acidity  of  body  fluids  below  normal,  and  inducing  a  lessened  resist- 
ance to  development  of  infective  causes,  and  that  caries  is  least  active 
in  the  hyperacid  individuals,  in  whom  sulphocyanid  of  potassium  is 
more  abundant  in  the  saliva.  He  has  also  claimed  to  have  found 
glycogen  in  the  saliva  of  adolescents. 

Kirk^  claims  that  in  the  caries  susceptible,  the  saliva  is  alkaline  to 
litEQus,  though  it  may  be  acid  to  other  reagents  (may  be  ampho- 
teric) .  That  the  alkalinity  keeps  the  mucinous  elements  in  solution, 
and  at  the  same  time  a  substance  analogous  to  glycogen  and  fer- 
mentable by  caries  bacteria  is  transuded  by  the  salivary  glands, 
which  furnishes  the  bacteria  their  pabulum  after  their  fixation  in 

1  Dental  Cosmos,  December,  1900. 

2  Items  of  Interest,  July,  1902,  p.  546. 


270  DENTAL  CARIES 

plaques  upon  the  teeth.  He  regards  this  glycogenic  principle  in  the 
saliva  as  due  to  carbohydrate  diet  in  excess  of  the  body's  needs 
and  its  capability  of  storage  as  fat;  that  it  enters  the  blood  after 
the  glycogenic  function  of  the  liver  has  been  exerted,  increases 
its  sugar  content  beyond  the  normal  of  0.001  per  cent.^  (Prinz 
states  it  as  0.06  to  0.11  present)  by  test  Kirk-  has  claimed  sugar  in 
the  saliva  of  diabetics,  but  Prinz^  in  his  tests  in  active  diabetes  denies 
its  presence  in  normal  or  pathologic  saliva.  He  regards  the  varia- 
tions in  susceptibility  as  due  to  variations  in  carbohydrate  diet. 

Kirk  has  succeeded  in  altering  viscid  saliva  to  a  more  limpid  condi- 
tion, by  reducing  the  ratio  of  carbohydrate  to  proteid  diet,  first  cutting 
out  carbohydrates  almost  altogether,  then  adding  them  gradually  to 
the  diet.  He  cites  observations  upon  asylum  children  kept  upon 
well-balanced  rations,  as  having  large  numbers  of  arrested  caries.* 

In  a  recent  article,^  the  possible  influence  of  the  hypophysis 
cerebri  upon  the  presence  of  an  excess  of  sugar  in  the  blood  and  of 
this  as  a  possible  explanation  of  caries  susceptibility,  is  treated  of 
by  Kirk,  who,  however,  disclaims  any  definite  finalit}^  at  present. 

Pickerill  argues  that  as  glycogen  is  rapidly  converted  into  maltose 
and  iso-maltose  by  ptyalin,  glycogen  and  ptyalin  should  be  chemi- 
cally incompatible.  He  states  that  in  his  examination  of  the  saliva 
of  diabetics  and  those  suffering  from  other  disease,  no  sign  of  glucose 
has  been  present.  Gies'^  tests  for  glucose  in  saliva  and  glycogen  in 
the  mucin  were  negative.  Taking  the  evidence  glucose,  in  saliva  even 
in  diabetes  is  not  proved.     (See  also  Lohmann  page  264.) 

Gies,^  conducting  elaborate  experiments  concerning  the  inhibitory 
effect  of  potassium  sulphocyanate  upon  plaque  formation,  concludes 
that  it  is  an  excretion  having  no  determined  bearing  upon  caries. 
Both  he  and  Howe^  found  experimentally  that  it  did  not  inhibit 
bacterial  growth  in  cultures.  Howe  considers  it  increases  the  gro'^'th. 
PickerilP  seems  to  have  found  a  different  conclusion,  but  in  an  inves- 
tigation of  fifty  ]Maori  immune  children  found  the  sulphocyanate 
extremeh'  low  and  in  22  per  cent,  absent.  The  Committee  on  Scientific 
Research  of  the  New  York  State  Dental  Society  furnish  the  following 
tests  for  it: 

Take  2  c.c.  of  saliva,  to  which  add  2  c.c.  of  distilled  water,  and 
shake  thoroughly  together.  Add  5  drops  of  iron  perchlorid,  and 
shake  again. 

1  See  Article  on  Caries  in  Fones's  Mouth  Hygiene,  p.  203. 

2  Dental  Cosmos,  January,  1914.  s  Ibid.,  AprH,  1918,  p.  292. 

^  Dental  Brief,  1907.  '  Dental  Cosmos,  January,  1914. 

6  Ibid.,  1914,  p.  408.  '  Ibid.,  913. 

8  The  Journal  of  The  Allied  Societies,  June,  1912. 
5  The  Prevention  of  Dental  Caries  and  Oral  Sepsis. 


PREDISPOSING  CAUSES  271 

The  presence  of  sulphocyanate  naturally  in  the  saliva  is  determined 
by  the  color. 

A  straw  color  indicates  little  or  none.  A  brick  color  indicates  a 
sufficiency.    A  wine  color  indicates  abundance. 

The  Committee  on  Scientific  Research,  of  the  National  Dental 
Association/  have  devised  a  colorimetric  scale  which  consists  of  two 
tubes.  In  tube  A,  1  c.c.  of  saliva  is  placed.  In  tube  B,  1  c.c.  of  a  1  to 
2000  solution  of  sulphocyanate  of  ammonia.  To  each,  add  2  drops 
of  a  5  per  cent,  ferric  chlorid  solution  from  the  same  pipette.  Add 
distilled  water;  to  be  in  definite  quantities  until  the  color  matches 
that  of  the  saliva.  Calculation  of  the  dilution  of  the  standard 
solution  will  give  the  amount  of  sulphocyanate  in  the  saliva.  The 
observations  are  introduced,  that  others  may  continue  the  line  of 
thought.  V 

The  use  of  potassium  or  sodium  smphocyanate  internally  in  j 
to  1  grain  doses,  in  tablet  form,  has  been  recommended  as  a  prophy- 
lactic, but  while  some  claim  value  it  is  quite  likely  that  other  means, 
such  as  oral  prophylaxis  conjoined  with  it,  have  had  much  to  do  with 
lessened  caries  and  hypersensitivity  of  dentin,  as  claimed. 

Potassium  sulphocyanate  is  described  as  a  nerve  tonic,  safe  in  even 
10  grain  doses.  It  must  not  be  confused  with  yotassium  cyanate,  which 
is  a  virulent  poison. 

Lohmann  reports  success  in  susceptibles  from  the  use  of  rhodalzia, 
a  combination  of  albumin  with  19.4  per  cent,  of  sulfocyanic  acid  in 
place  of  other  preparation. 

Black-  believes  that  the  condition  of  the  system  alters  the  oral 
fluid,  so  as  to  permit  the  bacteria  in  it  to  produce  a  gelatinoid  material 
as  a  by-product,  in  one  case  and  not  to  produce  it  in  another,  and 
that  when  produced,  plaques  adhere  to  the  teeth  in  sheltered  spots, 
while  when  not  produced  no  plaques  adhere,  though  a  general  acidity 
of  the  oral  fluids  may  be  produced. 

Miller,^  some  years  ago,  pointed  out  that  filthy  mouths  often  do 
not  contain  carious  teeth.  He  offered  the  rational  explanation  that 
the  unchanged  adhering  collections,  once  their  acid-producing  capa- 
city is  destroyed,  can  even  act  as  a  protection  in  so  far  as  caries  is 
concerned.  In  experiments  on  artificial  production  of  caries.  Miller 
found  that  the  pabulum  of  the  bacteria  needed  constant  change, 
otherwise  putrefaction  resulted  and  decay  ceased.  The  fact  that 
fairly  cared-for  mouths  often  contain  carious  teeth  is  rather  an 
argument  in  favor  of  the  local  etiology  of  caries,  as  teeth  unbrushed 

1  Dental  Cosmos,  1908,  p.  1365. 

2  Dental  Digest,  1907. 

s  Lecture  at  the  University  of  Pennsylvania. 


272  DENTAL  CARIES 

after  a  meal,  or,  rather,  not  thoroughly  cleansed,  as  is  the  rule  in  a 
vast  majority  of  mouths,  contain  every  necessary  factor  of  caries, 
including  a  renewal  of  fresh  carbohydrate  food  for  the  bacteria. 
As  prophylaxis  becomes  more  accurate,  mouths  usually  pass  into 
a  condition  suggesting  a  condition  of  immunity.  It  would  seem, 
therefore,  that  unless  some  other  factor  of  prophylaxis  can  be  intro- 
duced, the  mouth  should  either  be  thoroughly  cleansed  or  not  at  all, 
so  far  as  caries  is  concerned.  As  bearing  on  this  point,  a  patient  of  the 
writer,  about  forty-five  years  of  age,  was  for  years  an  immune  in  his 
hands  and  would  not  permit  his  teeth  to  be  cleansed.  He  was  finally 
persuaded  to  allow  it,  and  he  departed  from  his  immunity.  His  wife 
is  the  patient  referred  to  on  page  268. 

The  whole  subject  of  susceptibility  and  immunity  to  caries  is 
yet  obscure,  but  the  accurate  experimental  studies  are  seemingly 
gradually  approaching  the  conclusion  that  caries  is  a  question  of  the 
presence  or  absence  of  a  specific  local  cause. 


CHAPTER  IX 

DENTAL  CARIES:  PATHOLOGY,  MORBID  ANATOMY, 
AND  CLINICAL  HISTORY. 

PATHOLOGY   AND   MORBID   ANATOMY. 

It  is  a  fact  of  common  observation  that  caries  begins  only  at 
spots  protected  from  friction  or  uncleansed.  These  are  in  order  of 
frequency:  (1)  Pits,  grooves,  and  fissures  in  the  enamel;  (2)  approxi- 
mal  surfaces  just  above  the  contact  point;  (3)  smooth  surfaces  which 


Fig:  262 


Fig.  263 


Fig.  264 


Ffo,  2fi.5 


Fig.  266 


Fig.  273 


Fig.  267 


Fig.  268 


Fig.  271 


Fig.  272 


Fig.  275 


from  any  cause  are  habitually  unclean;  (4)  necks  of  the  teeth  at  or 
near  the  junction  of  the  cementum  and  enamel  (Black)  (Figs.  262 
to  275). 

In  these  situations  Williams  has  demonstrated  the  fact  that  the 
oral   bacteria,   protected   from   friction,   attach    themselves   to   the 
18  (273.) 


274 


DENTAL  CARIES 


enamel,  forming  microbic  plaques  which  are  sufficiently  adherent 
to  permit  their  retention  during  the  grinding  of  the  specimen  for 
microscopic  examination.  (See  Figs.  276,  277,  and  278.)  Carbo- 
hydrate food  debris  lodges  at  the  points  at  which  retention  is  favored, 
and  either  ferments  directly  against  the  enamel,  or  through  the 
medium  of  the  microbic  plaque. 

The  bacteria  in  the  plaque  require  food  and  obtain  it  from  the 
carbohydrate  and  albuminous  materials  which  come  in  contact  with 
them.     From  the  carbohydrates  lactic  acid  is  produced  as  a  waste 

Fig.  276 


Section  of  normal  human  enamel,  showing  thick,  felt-like  mass  of  microorganisms 
slightly  raised  from  the  surface  of  the  tissue,  by  pressure  of  the  cover-glass  in  mounting. 
X  250.     (Williams.) 


product.  (See  Chapter  VIII.)  Williams  states  that  it  is  "highly 
improbable  that  the  enamel  is  affected,  except  in  rare  and  special 
instances  by  any  other  acid  than  that  which  is  being  excreted  by  the 
bacteria  at  the  very  point  at  which  they  are  attached  to  the  enamel." 

This  thick  mass  of  fungi  also  prevents  the  excreted  acid  from 
being  washed  away,  so  that  it  exerts  its  full  chemical  power  upon 
calcific  tissue. 

The  lactic  acid   produced  attacks  the  inorganic  matter  of  the 


PATHOLOGY  AND  MORBID  ANATOMY 


275 


enamel,  following  first  the  interprismatic  cement  substance  between 
the  prisms,  later  dissolving  the  transverse  cement  substance  between 
the  globules.  The  effect  is  to  produce  an  irregular,  roughened  sur- 
face of  the  enamel  and  to  bring  into  view  the  structure  of  the  rods 
(Fig.  277).        . 

Fig.  277 


Microorganisnis  of  caries  attached  to  enamel  on  approximal  surface  of  tooth. 

(Williams.) 


The  gradual  loss  of  cement  substance  unbinds  the  enamel  globules, 
which  are  in  turn  dissolved  and  washed  away,  leaving  a  depression 
or  cavity. 

In  the  process  of  enamel  dissolution,  the  bacteria  may  enter  the 
crevices  formed  by  solution  of  the  interprismatic  cement  substance, 
and  by  repetition  of  the  process  gain  access  to  the  dentin  (Fig.  283). 

The  form  of  the  enamel  may  be  retained  until  and  even  after 
decalcification  has  reached  the  dentin.    Clinically,  this  is  seen  as  an 


276 


DENTAL  CARIES 

Fig.  278 


Superncial  approximal  caries  of  enamel  with  films;  also  shows   slight  approximal 
^abrasion.     (Miller.) 


Fig.  279 


Budding  of  spores  on  the  stems  of  Leptothrix  racemosa.     (Williams.) 


PATHOLOGY  AND  MORBID  ANATOMY 


277 


opaque  white  or  discolored  spot,  resisting  the  instrument  until  some 
force  is  used,  when  it  rapidly  breaks  down  (Figs.  278  and  284). 

A  central  cavity,  or  several  minute  openings,  leading  to  or  almost 
to  the  dentin,  is  sometimes  seen  in  the  general  decalcified  area.  It 
signifies  the  loss  of  the  organic  matter  of  the  enamel,  by  unbinding  or 
peptonizing  actions.  The  extraction  of  an  approximating  tooth 
permits  the  film  to  be  rubbed  off,  or  prevents  the  retention  of  carbo- 
hydrate media,  so  that  the  bacteria  cease  to  be  active,  and  this  spot 
may  remain  indefinitely  at  this  point — e.  g.,  the  disease  is  arrested. 
It  may  cease  spontaneously  to  develop  further,  owing  to  the  estab- 

FiG.  280 


A  form  of  streptococcus  found  abundantly  in  mouths  where  very  rapid  decay  of  teeth 
is  in  progress.     X  750.     (Williams.) 


lishment  of  an  immunizing  systemic  change,  even  though  the  teeth 
remain  in  approximation,  and  strict  prophylaxis  will  usually  arrest 
the  advance  of  the  process. 

It  is  also  noted  clinically  and  microscopically  that  the  decalcifica- 
tion is  deepest  at  a  spot  just  above  the  point  of  contact,  and  less 
deep  at  points  buccal  or  lingual,  occlusal  or  cervical,  to  this  spot, 
and  still  less  at  points  more  buccal  or  lingual — i.  e.,  it  shades  off  to 
zero  lingually,  buccally,  occlusally,  and  cervically  (Fig.  284).  The 
dentin  may  in  such  cases  be  deeply  affected  even  before  enamel  con- 
tour is  lost.     Bacteria  growing  in  the  spaces  from  which  the  inter- 


278 


DENTAL  CARIES 


prismatic  cement  substance  has  disappeared,  causes  detachment  of 
masses  of  partially  decalcified  rods  (Fig.  285) . 

When  the  entire  thickness  of  the  enamel  is  penetrated  and  the 
dentin  attacked,  there  is  a  change  in  the  mode  of  progress  of  the 
decalcification,  which  proceeds  along  the  line  of  union  between  the 
enamel  and  dentin,  as  well  as  directly  into  the  dentin  (Fig.  284);  in 
this  way  the  enamel  is  attacked  from  its  dentinal  side  (backward 
caries)  (Fig.  282). 

Fig.  281 


Section  of  human  bicuspid,  showing  commencement  of  caries:  a  and  a',  appearances 
caused  in  enamel  and  dentin  by  the  acid  of  decay;  b  and  b^,  shreds  of  a  felt-like  mass 
of  bacteria  raised  from  the  surface  of  the  enamel;  c,  a  cavity.     X  12.     (Williams.) 


In  the  ultimate  breaking  down  of  the  enamel  the  rods  first  separate; 
the  outlines  of  the  several  globules  of  which  the  rods  are  composed  are 
brought  into  plain  view;  next,  the  calcified  plasmic  strings  noted  in 
enamel  formation  become  evident;  and  finally,  the  bead-like  masses 
upon  these  strings  are  left  as  the  ultimate  granular  detritus  of  the 
enamel. 

Some  of  the  ^bacteria  in  the  plaque  are  not  acid  producers,  and  it 
may  be  that  if  a  film  is  composed  entirely  of  these,  they  may  occupy 
a  field  and  really  protect  it  by  excluding  acid-forming  bacteria. 


PATHOLOGY  AND  MORBID  ANATOMY 


279 


Caries  of  Nasmyth's  Membrane.— Miller^  demonstrated  that  the 
enamel  cuticle  may  act  as  a  breeding  ground  for  many  forms  of 


Fig.  282 


Section  of  carious  tooth,  showing  appearances  of  decay  in  enamel  and  dentin  at  the 
line  of  union  of  these  tissues;  the  dark  spots  shown  in  the  enamel  and  dentin  are 
masses  of  microorganisms.      X  250.     (Williams.) 


Fig.  283 


Penetration  of  bacilli  between  enamel  prisms  after  solution  of  interprismatic  cement 

substance.     (Miller.) 

1  Microorganisms  of  the  Human  Mouth,  1890,  and  Dental  Cosmos,  1900. 


280 


DENTAL  CARIES 


bacteria  ^viiich  occupy  it,  forming  a  matrix  which  may  retain  minute 
particles  of  food,  which  in  turn  aid  in  acceleration  of  the  progress 
of  decay  (Figs.  284,  288  and  290). 

Caries  of  Dentin. — ^The  bacteria,  after  penetrating  the  substance 
of  the  enamel,  attack  the  dentin.  This  presents  a  different  anatomical 
and  chemical  structure  to  be  acted  upon.  Beneath  the  enamel,  the 
first  layer  of  dentin  is  of  a  composition  which  permits  the  bacteria 
to  rapidly  spread  laterally  along  this  zone.     They  also  enter  the 

Fig.  284 


Decalcification  of  enamel  without  loss  of  form;  a,  film.     X  35.     (Miller.) 


tubules  of  the  dentin,  and  penetrate  by  multiplication,  toward  the 
pulp.    A  wedge-shaped  area  of  decay  is  produced  (Figs.  284  and  291). 

In  all  cases  decalcification  precedes  these  invasions.  At  the 
periphery,  the  tubules  communicate  freely  by  their  lateral  branches 
(Fig.  289).  and  the  lateral  spreading  of  the  bacteria  by  multiplication 
is  readily  explained. 

It  is  seen  clinically  in  caries,  that  a  portion  of  the  dentin  is  abso- 
lutely destroyed  and  removed,  leaving  within  the  tooth  a  "  cavity  of 


PATHOLOGY  AND  MORBID  ANATOMY 


281 


decay,"  bounded  by  dentin  and  enamel  undergoing  disintegration; 
beneath  this  Kes  dentin  less  affected,  and  beneath  this,  sound  dentin 
(Fig.  291).    These  phenomena  require  explanation. 

The  tubules  of  the  decalcified  dentin  become  packed  for  a  distance, 
with  bacteria  (Fig.  289).    These  act  upon  the  organic  matrix  of  the 

Fig.  285 


Cover-glass  preparation  from  scrapings  of  white,  opaque,  decaying  enamel;  the 
cement  substance  between  the  rods  is  seen  to  be  dissolved  away,  and  the  crevices  thus 
formed  are  filled  with  round  and  oval  forms  of  micrococci  and  bacteria.  Stained  by 
the  Gram  method.     X  450.    (WUliams.) 


decalcified  tubule  walls.  The  internal  pressure  due  to  multiplication 
distends  them  so  that  the  lumen  is  enlarged.  At  the  same  time,  the 
bacteria  excrete  a  ferment  or  ferments  which  cause  the  wall  at  first 
to  thicken.  The  dilatation  and  thickening  together  cause  the  com- 
pression of  the  decalcified  intertubular  substance,  and  the  tubules 


1^2 


DENTAL  CAttlM 
Fig.  286 


Various  forms  of  micrococci  and  bacteria  from  decaying  enamel.       Photographed  by 
Mr.  Andrew  Pringle  from  Williams'  cover-glass  preparation.     X  1000.   (Williams.) 


Yw.  2s7 


Cover-glass  preparations  of  scrapings  from  decay  of  enamel;  shows  Leptothrix 
buccalis  maxima  and  Bacillus  buccalis  maximus,  of  Miller.  Stained  by  Gram  method, 
X  830.     (Williams.) 


PATHOLOGY  AND  MORBID  ANATOMY 


28g 


assume  a  hexagonal  shape  owing  to  the  mutual  pressure  (Fig.  293). 
The  phenomenon  is  not  a  vital  one,  as  it  occurs  in  artificial  caries. 
(Miller.) 


FiQ.  288 


Enamel  cuticle  permeated  by  bacteria     (1100  to  1.)     (Miller.) 
Fig.  289 


Carious  dentin,  stained  with  fuchsin  to  show  microorganisms.  The  section  shows 
the  condition  of  the  tubules  as  filled  with  microorganisms  along  the  junction  of  the 
dentin  with  the  enamel  at  a.  The  tubules  are  very  much  enlarged.  (1/10  immersion 
objective.)     (Black.)    Also  explains  anastomosis  of  fibrils  and  indirect  transmission  of 

sensation.     (Editor.) 

The  bacterial  ferment  possesses  a  digestive  or  peptonizing  power, 
analogous  to  trypsin,  and  begins  to  liquefy  the  inner  surface  of  the 
tubule  wall.     As  it  does  so,  the  lumen  is  further  increased  and  the 


284 


DENTAL  CARIES 


bacteria  fill  the  acquired  space.  Taking  up  carbohydrates,  lactic 
acid  is  produced,  which  combines  with  the  calcium  salts  of  deeper 
tubules  and  intertubular  substance  and  prepares  a  path  of  decal- 
cified tissue  for  bacterial  advance  (Fig.  294) .  This  decalcified  tissue, 
to  all  intents  and  purposes,  becomes  a  culture  medium.  Calcium 
lactophosphate,  calciimi  lactate,  and  magnesium  lactophosphate  are 
produced. 

As  stated  by  Howe  some  of  the  bacteria  can  withstand  even  14 
per  cent,  of  lactic  acid  though,  of  course,  decalcification  neutralizes 
acid  which  is  again  produced  by  fermentation  of  arriving  carbohy- 
drates.   Kirk  has  theorized  that  bacteria  find  in  dentin  a  fermentable 

Fig.  290 


Persistence  of  Nasmyth's  membrane  in  occlusal  fissure.      (M.  T.  Barrett.) 

carbohydrate  food  substance  which  leads  them  in  that  direction. 
Gies^  states  that  a  gly co-protein  is  to  be^found  in  dental_^  substances 
and  remarks  that  this  lends  color  to  the  theory. 

The  bacterial  ferments  continue  to  digest  the  wall  of  the  tubule, 
and  a  time  arrives  when  they  have  penetrated  its  substance.  The 
intertubular  substance  is  then  removed  in  like  manner.  The  same 
process  occurring  in  adjoining  tubules  as  well,  the  entire  dentinal 
substance  in  the  particular  area  at  the  cavity  surface  is  destroyed — 
i.  e.,  liquefied  and  washed  away  (Fig.  291,  a).    A  cavity  results. 

When  the  process  is  active  at  a  point  beneath  the   general  cavity 


1  Dental  Cosmos,  1917,  p.  1241. 


PATHOLOGY  AND  MORBID  ANATOMY 


285 


surface,  the  bacteria  in  several  adjoining  tubules  destroy  their  walls 
and  the  intervening  intertubular  substance,  forming  what  ]\Iiller  has 


Fig.  291 


Longitudiaal  ground-section  through  the  crown  of  an  inferior  molar  of  a  negro: 
E,  enamel;  D,  dentin;  C,  cement;  p,  pulp  chamber;  a,  large  decay,  frona  the  occlusal 
surface;  h,  small  decay,  from  the  mesial  surface;  c  s,  cone  of  septic  invasion  and 
discoloration ;  e,  partially  decalcified  and  discolored  enamel  around  the  carious  cavity ; 
z,  dark  cones;  z',  clearer  cones;  z'p,  oldest  cones  where  putrefaction  of  the  tooth  cartilage 
begins;  c,  outer  transparent  zone,  or  zone  of  Tomes;  s  d,  secondary  dentin,  caused  by 
irritation;  s'  d',  secondary  dentin  deposited  by  normal  physiological  process,  recession 
of  the  pulp.  This  figure  is  drawn  from  a  ground  and  polished  section  mounted  in 
Canada  balsam.     (Gysi.) 


286 


DENTAL  CARIES 


called  a  "liquefaction  focus"  (pi.  foci)  (Fig.  295).    This  action  pro- 
ceeds until  the  enamel  is  undermined  and  the  pulp  is  exposed.    A 

decalcified  area  always  exists  in  advance 
^^°-  292  of  the  tubule  invasion,  sometimes  large 

masses  being  found,  though  it  lessens  in 
quantity  as  the  pulp  is  approached.  As 
the  enamel  is  undermmed  by  the  carious 

Fig.  293 


Carious  dentin,  showing  in- 
invaded  tubules  and  uninvaded 
but  decalcified  intertubular 
substance.    (Miller.) 


Cross-section  of  decayed  dentin:  the  tubules 
through  reciprocal  pressure  have  assumed  the 
shape  of  five-  and  six-sided  prisms.     (Miller.) 


process,  the  bacteria  and  their  acids  decalcify  its  inner  surface,  the 
process  proceeding  from  within  outward,  and  termed  "secondary 
caries,"  or  "backward  caries,"  of  enamel  (Figs.  282  and  304). 


Fig.  294 


Mll^pl^;^ 


y' 


./ 


Section  of  decalcified  dentin  partly  invaded  by  bacteria:  a,  uninvaded  zone.    (Miller.) 


The  enamel  is  thus  weakened  and  at  the  same  time  deprived  of 
dentinal  support,  and  breaks  down  under  stress  of  mastication. 


PATHOLOGY  AND  MORBID  ANATOMY 


287 


Any  interglobular  spaces  in  the  dentin  being  filled  with  transi- 
tional or  uncalcified  material  like  the  tubule  walls  are  rapidly  invaded 
by  the  bacteria  during  their  progress  along  the  tubules  (Fig.  297). 

The  character  of  the  organisms  in  the  tubules  and  the  nature  of 
the  liquefaction  seem  to  depend  upon  the  particular  germs  present. 

Miller  has  shown  that  in  the  deeper  portions  of  tubules  micrococci 
appear  to  predominate  over  the  rod  forms,  which  are  also  present; 


Fig.  295 


Fig.  296 


If  IS 


Liquefaction  foci.     (Miller.) 


Decayed  dentin  showing  a 
mixed  infection  with  cocci  and 
bacilli.       X    400.      (Miller.) 


although  one  tubule  may  be  filled  with  cocci  and  its  neighbor  with 
rod  forms  (Fig.  296).  It  is  only  in  the  more  superficial  layers  that 
the  thread  forms  are  found  in  numbers. 

Goadby^  has  done  much  interesting  work  in  this  direction,  and 
offers  the  following  classification  of  bacteria  found  in  decayed  dentin 
to  which  list  must  be  added  those  found  by  Howe  and  as  hinted  *by 
him  may  largely  be  accidental. 


1  Mycology  of  the  Mouth,  and  Dental  Cosmos, 


288 


DENTAL  CARIES 


Bacteria  op  Dental  Caries. 


Acid-forming  Bacteria. 


Streptococcus  brevis 
B.  necrodentalis    . 
Staphylococcus  albus 
Streptococcus  brevis 
Sarcina  lutea   . 
Sarcina  aurantiaca 
Sarcina  alba  (Eisenberg) 
Staphylococcus  albus 
Staphylococcus  aureus 


Deep  layers  of  carious  dentin. 


>  Superficial  layers  of  carious  dentin 


Bacteria  which  Liquefy  Dentin  (Decalcified.) 


None  isolated  as  yet 
B.  mesentericus  ruber 
B.  mesentericus  vulgatus 
B.  mesentericus  fuscus    . 

B.  fervus    

B.  gingivae  pyogenes 

B.  liquefaciens  fluorescens  motilis 

B.  subtilis 

Proteus  Zenkeri 

B.  plexiformis 


Deep  layers  of  carious  dentin. 


Superficial  layers  of  carious  dentin. 


Goadby  states  that  his  experiments  show  that  the  bacteria  which 
dissolve  blood  serum  also  digest  decalcified  dentin,  while  those  which 
only  liquefy  gelatin  do  not  digest  decalcified  dentin. 

His  experiments  also  indicate  that  of  the  bacteria  found  in  the 
superficial  layers  of  carious  dentin  some  produce  digestive  enzymes, 
others  acid  fermentation,  and  others  have  both  functions. 

Choquet^  has  confirmed  the  observation  of  Miller,  Vignal,  Gallipe, 
and  Goadby  that  the  deeper  the  portions  of  dentin  examined,  the 
fewer  species  of  fungi  are  found  in  the  tubules,  and  explains  it  upon 
the  ground  that  the  anaerobic  or  facultative  aerobic  organisms  in  the 
outer  layers  advance  into  the  deeper  dentin,  because  they  are  better 
suited  to  the  conditions.  Kirk  advances  the  as  yet  unproven  idea 
that  these  bacteria  grow  toward  the  pulp,  because  that  is  the  direc- 
tion of  their  food  supply,  i.  e.,  the  juices  in  the  protoplasm  of  the  part. 
In  this  connection,  the  demonstration  of  Goadby  that  some  bacteria 
liquefy  decalcified  dentin  shows  that  this  substance  is  a  food  supply. 

These  exact  findings  are  interesting  as  bearing  out  the  general 
demonstrations  of  Miller;  at  the  same  time,  Miller's  experiment 
showing  absolute  dissolution  by  a  single  bacterium  in  pure  culture  is 
to  be  recalled.     (See  page  247.) 

Choquet^  has  shown  that  dental  caries  may  proceed  under  fillings 
against  sound  dentin  by  the  following  experiment: 

Artificial  cavities  were  prepared  in  the  incisors  of  a  sheep.  In  these 
was  securely  sealed  with  cement,  a  small  particle  of  a  gelatin  culture 


1  Microbes  of  Dental  Caries,  Dental  Cosmos,  1900, 

2  Ibid. 


PATHOLOGY  AND  MORBID  ANATOMY 


289 


of  caries  fungi,  applied  on  a  sterilized  platinum  cap.  Nine  months 
later  the  dentin  had  become  yellow,  slightly  decalcified,  and  the 
tubules  penetrated  b}^  bacteria.  This  softened  dentin  was  used  to 
inoculate  a  portion  of  the  medium  originally  used,  and  the  species 
again  cultivated. 

Miller^  estimated  the  relative  loss  of  inorganic  and  organic  matter 
in  dentin  during  the  process  of  caries,  by  weighing  and  analyzing 
equal  volumes  of  carious  and  sound  dentin  from  the  same  teeth. 


Fig.  297 


:l 


// 


W  ,  //-^//.yV/M.//.^ 


\ 


Interglobular  spaces  filled  with  bacteria.   (Miller.) 


The  carious  dentin  had  lost  about  seven-ninths  of  its  weight, 
which  was  due  to  the  loss  of  twelve-thirteenths  of  its  original  calcium 
salts  by  decalcification,  and  two-fifths  of  its  original  organic  matter 
by  liquefaction  of  its  substance. 

Tube  Casts. — In  the  zone  of  decalcification,  in  advance  of  bacterial 
invasion  of  the  tubes,  are  found  rod-shaped  bodies  or  shining  granules, 
first  described  by  J.  Tomes.    They  occur  in  both 
natural  and  artificial  caries,  hence  it  must  be  I'l^.  298 

inferred  that  their  presence  is  not  the  result  of  a 
vital  process. 

The  rods  do  not  dissolve  in  organic  acids, 
but  dilute  sulphuric  acid  quickly  dissolves 
them.  They  are  unaffected  by  alcohol  or 
chloroform,  a  proof  that  they  are  not  composed 
of  fat.  Miller  regards  them  as  probably  calcic 
formations  against  the  tubule  wall  as  a  cast  of 
the  wall,  and  which  become  loosened  when  en-  Tube  casts. 

largement  of  the  tubule  occurs.     They  have  a 
tubular  structure,  are  brittle,  and  may  contain  a  central  thread-like 
filament  which  may  possibly  be  the  remains  of  a  dentinal  fibril. 


19 


*  Microorganisms  of  the  Human  Mouth. 


290 


DENTAL  CARIES 


Bacteria  may  surround  them,  but  do  not  enter  them.  The  granules 
are  probably  broken  rods.^  The  data  point  toward  a  probability 
that  the  rods  are  composed  of  calcium  lactate  and  calcium  lacto- 
phosphate,  the  result  of  a  combination  of  lactic  acid  with  the  calcium 
salts  of  the  dentin.  The  resultant  salt  is  probably  deposited  as  a 
tube  cast,  as  suggested  by  Miller. 

The  Transparent  Zone. — Around  the  zone  of  decalcified  uninfected 
dentin  appears  a  zone  of  dentin  more  transparent  than  the  surround- 
ing normal  dentin.    The  zone  extends  from  periphery  to  periphery 

Fig.  299 


Section  from  a  lower  incisor  worn  on  a  plate,  extensive  decay  without  increase  of 
transparencs^    X  15.     (Miller.) 

around  the  cone  of  carious  dentin  (Fig.  291,  c).  The  tubules  in  this 
area  contain  granular  matter  not  seen  in  normal  dentin,  nor  in  the 
dentin  of  dead  teeth  in  the  same  situation. ^ 

Tomes  and  Magitot  both  regarded  the  transparency  as  an  attempt 
made  by  nature  to  impede  the  progress  of  caries.  Walkhoft'  regards 
it  as  due  to  a  sclerotic  action,  the  fibrillse  upon  stimulation  producing 
intercellular  substance  (tubule  wall),  at  their  own  expense  and 
primarily  of  their  offshoots.    Miller  advanced  the  following  data.^ 


1  Microorganisms  of  the  Human  Mouth. 


2  Ibid. 


3  Ibid. 


PATHOLOGY  AND  MORBID  ANATOMY 


291 


1.  Transparency  indicates  increased  homogeneity  as  opposed  to 
the  heterogeneity  of  normal  dentin — i.  e.,  the  coefficients  of  Ught 
refraction  are  brought  nearer  together. 

2.  It  occurs  in  Hving  dentin  only  and  is  not  found  in  natural  teeth 
mounted  on  plates  and  decayed  in  the  mouth,  nor  in  secondary  caries 
of  dentin  from  the  pulp  cavity  to  the  periphery,  and  is,  therefore,  a 
result  of  vital  action.  (Compare  Figs.  291  and  301  with  Figs.  299 
and  300.) 

3.  The  tubules  have  their  lumen  lessened  in  diameter  in  the  trans- 
parent areas,  an  agreement  with  the  position  of  Walkhoff . 

Fig.  300 


Secondary  caries  of  dentin,  advancing  from  pulp  chamber  and  therefore    occurring 
after  death  of  the  pulp.  Absence  of  transparency.    X  15.  (Miller.) 


4.  Secondary  dentin  may  accompany  the  process  in  contiguity 
with  the  area;  moreover,  secondary  dentin  is  translucent.  It  indi- 
cates a  constructive  excitation  of  the  odontoblasts,  of  which  the 
dentinal  fibrils  are  prolongations  (Figs.  291,  Sd). 

5.  Chemical  analysis  proved  that  no  lime  salts  had  been  lost,  and 
it  was  pointed  out  that  a  gain  in  the  percentage  of  salts  was  unneces- 
sary, as  new  dentin  is  necessarily  composed  of  organic  as  well  as 
inorganic  matter,  wherefore  the  analysis  would  not  necessarily  vary 
from  that  of  normal  dentin. 


292 


DENTAL  CARIES 


6.  It  is  found  in  connection  with  abrasion  of  human  teeth  in  which 
the  activity  of  acid  may  possibly  be  an  open  question,  and  it  also 
occurs  in  the  worn  teeth  of  dogs,  the  saliva  of  which  is  strongly 
alkaline. 

Miller  states  that  opacity  may  follow  or  be  associated  with  trans- 
parency.^ 

The  natural  conclusion  is  that  the  transparency  is  a  form  of 
tubular  calcification,  and  that  it  impedes  the  progress  of  caries;  that 
it  does  not  succeed,  as  a  rule,  is  due  to  the  overwhelming  action  of 
the  bacteria. 

Fig.  301 


Transparency  resulting  from  cracks  in  the  enamel  at  a  and  h.      X  20.     (Miller.) 


In  cavities  from  which  the  walls  are  broken  away,  freely  exposing 
the  carious  dentin  to  mastication,  the  carious  dentin  and  its  con- 
tained bacteria  may  be  removed  by  friction  (Fig.  305,  B). 

Transparency  may  begin  even  before  caries  has  penetrated  the 
enamel-  and  Fig.  301  shows  that  it  may  begin  before  the  enamel  is 
worn  away.  There  would  seem  to  be  some  possible  fibrillar  relation 
in  such  cases  (see  page  144). 

In  the  transparent  area,  the  tubules  become  obliterated;  a  polished, 
discolored  surface  results,  resembling  in  degree  an  abraded  surface. 

1  Dental  Cosmos,  April,  1903. 

2  Kirk,  in  Fones'  Mouth  Hygiene,  p.  200. 


PATHOLOGY  AND  MORBID  ANATOMY  293 

This  process  is  called  "eburnation,"  and  is  really  tubular  calcifica- 
tion (which  see).  In  the  same  tooth  a  more  sheltered  border  of  this 
spot  may  be  undergoing  the  carious  process.  Miller  records  cases  of 
badly  decayed  teeth,  in  which  the  process  ceased  spontaneously  and 
the  dentin  became  hard  and  smooth. 

Pigmentation  in  Caries. — Pigmentation  occurs  in  caries  possibly 
from  extraneous  substances  entering  the  carious  area,  possibly  from 
the  substances  formed  during  putrefaction. 

The  slower  the  progress  of  the  decay,  the  greater  the  discoloration. 
The  colors  vary  from  light  yellow  to  reddish  brown,  dark  brown, 
and  black. 

The  color  is,  as  a  rule,  darkest  upon  the  outside  of  the  carious 
dentin,  but  the  pigment  may  extend  through  large  masses  and  be 
found  staining  dentin  beneath  the  caries,  hard  enough  to  leave  in 
situ.    As  a  rule,  this  is  not  the  case. 

Black  suggests  the  possible  formation  of  sulphids.  jNIiller  has 
found  iron  almost  constantly  present  in  carious  dentin.  The  dis- 
coloration of  dentin  does  not  seem  to  be  necessarily  due  to  the 
carious  process,  as  it  may  be  seen  in  areas  of  abrasion.  In  a  specimen 
possessed  by  the  editor,  a  limited  cervical  caries  caused  a  growth  of 
secondary  dentin  and  an  area  of  tubular  calcification.  From  the 
pulpal  surface  of  the  secondary  dentin  to  the  area  of  caries,  extends 
a  sharply  defined  area  which  has  a  flesh-rose  color  (Fig.  302) .  Many 
areas  of  secondary  dentin  due  to  abrasion  are  stained  a  dark 
brown. 

Artificial  caries  produced  in  teeth  placed  in  a  mixture  of  bread 
and  saliva,  and  the  mixture  constantly  renewed,  was  white.  If  putre- 
faction was  allowed  to  occur,  discolorations  ensued  (Miller). 

The  discolorations  of  carious  dentin  may  be  due  to  the  action  of 
chromogenic  bacteria.  Miller  isolated  from  the  mouth,  an  organism 
which  he  named  Bacillus  fuscans,  and  "which,  cultivated  on  the 
surface  of  nutritive  agar-agar,  in  a  few  weeks  imparts  to  the  medium 
a  yellowish-brown  color,  which  gradually  darkens  and  extends 
deeper  into  the  substratum  as  the  age  of  the  culture  increases." 

It  is  significant  that  the  three  acid-forming  organisms  found  by 
Goadby,  in  the  deep  layers  of  carious  dentin,  do  not  form  pigment 
in  their  artificial  media.  The  action  of  acidific  bacteria  may  yet  be 
shown  to  be  responsible  (see  page  250) . 

Caries  of  Cementum. — Caries  of  cementum  occurs  when  the  gum 
has  receded,  exposing  the  cementum  to  the  fluids  of  the  mouth.  As 
a  rule,  a  triangular  depression  exists  bounded  by  the  thickened  gum 
margin,  the  cementum,  and  the  enamel.  This  favors  the  collection 
of  the  bacterial  plaques,  and  caries  follows.    The  gum  may  be  much 


294  DENTAL  CARIES 

receded,  yet  no  caries  occurs.  As  a  rule,  however,  recession  and 
uncleanliness  frequenth^  assure  its  presence.  Especially  is  this  true 
in  cases  of  general  recession  in  aged  or  debilitated  persons.  (Fig.  302) . 
The  path  of  bacterial  invasion  after  decalcification,  is  by  way  of 
Sharpey's  fibers  to  the  lacunae  and  canaliculi;  later  the  dentin  is 
invaded  as  in  the  crown.  Frequently  the  form  of  the  cementum  is 
largely  retained,  while  the  decalcification  is  deep. 

Fig.  302  Fig.  303 


Cervical  caries  associated  with  secondary  Caries  of  cementum  and  dentin  com- 

dentin.  Area  pigmented.  pletelj'  encircling  the  tooth. 


CLINICAL   HISTORY    OF    CARIES. 

The  clinical  history  of  dental  caries  records  the  observable  phe- 
nomena associated  with  its  inception,  progress,  and  termination. 

Inception  of  Caries. — Caries  begins,  after  the  manner  described 
in  the  pathology,  at  favoring  spots.  As  a  rule,  in  molars  the  occlusal 
fissures  are  first  decayed,  being  often  carious  in  this  situation  before 
fully  erupted.  Uninformed  parents  usually  consider  the  first  perma- 
nent molar  a  temporary  one,  and  frequently  neglect  it.  It  moreover 
has  often  seriously  defective  fissures,  which  afford  lodgement  for 
microbic  plaques,  which  seem  to  be  readily  formed  because  of  the 
unhygienic  state  of  the  temporary  teeth,  which  are  frequently 
carious,  and  the  permanent  molars  are  unbrushed  during  eruption. 
Not  infrequently  a  cavity  is  produced  on  the  mesial  surface  of  this 
tooth  by  a  carious  condition  of  the  distal  surface  of  the  second 
temporary  molar.  In  other  mouths,  both  teeth  are  affected  alike, 
owing  to  the  nature  of  the  approximation.  The  relative  liability  of 
the  various  surfaces  of  the  different  teeth  to  caries  may  be  averaged 
for  a  great  number  of  persons,  but  tables  drawn  from  clinical  cases 
may  have  little  application  to  a  particular  individual,  as  peculiarities 
of  local  predisposing  causes  and  personal  habits  modify  the  inception. 
Nevertheless,  such  tables  are  exceedingly  interesting  as  showing  a 
general  relative  liability. 


CLINICAL  HISTORY  295 

The  following  is  from  the  U.  S.  Army  report,  70,000  teeth  being 
filled. 

Average  percentage 
Teeth.  of  each  carious. 

First  permaneat  molars 6.5 

Second  permanent  molars 5.1 

Upper  central  incisors 3.9 

Premolars 2.8 

Third  molars 2.0 

Upper  canines 1.7 

Lower  incisors 0.7 

Lower  canines 0.5 

The  lower  anterior  teeth  are  the  last  of  all  to  be  affected,  and  it  is 
common  to  see  the  six  lower  anterior  teeth  free  from  caries,  years 
after  all  of  the  other  teeth  have  been  lost.  This  is  attributable  to 
the  constant  motion  of  the  saliva,  the  presence  of  calculus,  and  to 
the  mechanical  effects  of  tongue  movement,  lip  movement,  and 
mastication. 

In  the  temporary  set,  the  molars  decay  much  more  frequently  than 
the  incisor  teeth,  partly  because  longer  retained  and  partly  because 
of  the  width  of  their  approximations.  The  pulp  is  readily  exposed 
because  of  its  relatively  larger  size, 

Approximal  cavities  are  frequently  more  broad  than  deep,  and 
present  problems  of  anchorage. 

The  Progress  of  Caries. — ^The  rapidity  of  progress  of  caries  depends 
upon  the  intensity  of  the  action  of  the  exciting  cause,  the  structure 
of  the  tooth,  and  the  nature  of  the  vital  resistance  offered.  The 
exciting  cause  will  act  most  intensely  in  mouths  ill-cared  for,  and 
containing  much  carbohydrate  debris,  and  these  conditions  being 
equal,  enamel  of  poorer  organization  and  presenting  a  greater  degree 
of  solubility,  in  teeth  presenting  broad  approximations,  will  be  the 
more  rapidly  destroyed.  Caries  does  not  begin,  but  may  spread 
under  the  gum. 

Williams  has  expressed  the  opinion  that,  as  a  rule,  the  process  of 
enamel  destruction  occupies  a  considerable  period  of  time,  a  fact 
which  may  account  for  the  general  lack  of  caries  in  the  temporary 
teeth  until  about  four  or  five  years  of  age. 

The  decalcified  enamel  may  retain  its  form  for  a  time  after  dentin 
decalcification  has  begun.  An  opaque  spot,  often  discolored,  is 
seen  upon  the  tooth,  and  is  readily  broken  down  by  an  instrument 
before  dentin  decalcification  occurs,  though  such  decalcification  is 
often  found.  If  the  approximating  tooth  be  extracted,  the  carious 
process  may  cease,  owing  to  the  removal  of  the  bacterial  plaque,  or  a 
lack  of  food  supply  (retention).  This  result  may  not  follow,  if  the 
dentin  has  been  invaded  before  the  extraction. 


296 


DENTAL  CARIES 


After  enamel  destruction  at  a  limited  area,  caries  progresses  along 
its  inner  side  and  penetrates  the  dentin.  The  enamel  is  undermined. 
The  extent  of  cavity  orifice  is  no  certain  guide  as  to  the  depth  of 
penetration.    The  under  surface  of  the  enamel  then  decalcifies.    This 


Fig.  304 


Caries  undermining  enamel:  a,  masses  of  bacteria  lining  the  ca^dty.     X  50.    (Miller.) 
This  may  lead  to  the  appearance  in  Fig.  306. 


is  backward  or  secondary  decay  of  enamel,  and  causes  an  opaque 
appearance  of  the  undermined  enamel.     (Figs.  304,  305,  A.) 

Cases  are  frequently  observed,  in  which  the  only  external  evidence 
of  caries,  in  a  molar  or  bicuspid,  is  a  white  or  bluish-black  line  marking 


CLINICAL  HISTORY 


297 


the  fissure,  and  yet  the  dentin  may  be  deeply  and  widely  penetrated 
(Fig.  305,  .4).    ' 

As  a  rule,  however,  as  the  cavity  in  the  dentin  enlarges,  the  enamel 
at  the  orifice  becomes  disintegrated,  so  that  the  orifice  is  enlarged 
and  more  food  debris  enters  to  accelerate  the  process  (Fig.  291).  A 
deep  and  wide  cavity  may  thus  be  formed  before  the  patient  is 
objectively  or  even  subjectively  aware  of  its  existence.  xVfter  a 
time,  the  occlusal  enamel  boundary  of  the  cavity  breaks  down  and 
food  is  even  more  readily  admitted. 

It  has  been  noted  that  if  the  enamel  break  away  in  such  a  manner 
as  to  expose  the  carious  dentin  to  the  friction  of  food  masses  which 
are  not  retained  and  to  the  access  of  saliva,  the  progress  of  the 
caries  is  delayed  and  in  some  cases  ceases  altogether.  The  process 
of  eburnation  is  set  up.  (See  Transparent  Zone  and  Tubular 
Calcification.)     (Fig.  305,  B.) 

Fig.  306 


Spreading  caries  in  a  molar  with  some  enamel  remainino 
explain  the  process. 


Fig.  304  -n-ill 


The  process  is  sometimes  seen  in  certain  cases  in  which  caries 
has  followed  the  dento-enamel  junction,  the  enamel  chipping  off 
as  undermined,  so  that  almost  the  entire  superficial  portion  of  the 
dentin  may  be  subjected  to  this  process  and  remain  of  original  form 
and  discolored  and  eburnated.  This  is  "spreading  caries"  (Fig.  306). 
In  other  cases  the  tubules  are  followed  and  the  pulp  is  rapidly 
approached.    This  is  "penetrating  caries"  (Fig.  291). 

Caries  may  progress  rapidly  for  a  period,  and  then  receive  a  check 
to  its  progress.  Teeth  previously  free  from  the  disease  may  suddenly 
fall  victims  to  its  rapid  and  widespread  progress.  No  doubt,  in  many 
of  these  cases,  there  are  removed  from  or  added  to  the  local  oral 
conditions,  constitutional  influences  which  deter  or  favor  the  local 
development  of  caries  producing  bacteria.  The  editor  has  the  models 
of  the  jaws  of  a  boy,  aged  fourteen  years,  with  every  tooth  but  three 
decayed  to  the  gum,  and  the  three  teeth  contained  six  cavities. 

Secondary  dentin  is  less  readily  decalcified  than  primary  dentin. 


298  DENTAL  CAttlES 

The  dentin  of  pulpless  teeth  is  more  rapidly  invaded  after  enamel 
decalcification  than  that  of  vital  teeth,  owing  to  the  absence  of  vital 
resistance.  This  condition  does  not  necessarily  apply  to  the  enamel 
of  pulpless  teeth. 

While  caries  appears  at  all  ages  from  childhood  to  old  age,  its 
ravages  are  most  pronounced  and  its  progress  most  rapid  during  the 
period  of  adolescence  and  early  maturity.  Its  effects  are  most 
marked  between  the  ages  of  eight  and  twenty-five  years.  As  a  rule, 
a  denture  which  remains  at  twenty-five  years  unaffected  by  caries, 
remains  unaffected  or  but  slightly  affected  to  an  indefinite  age.  To 
be  sure,  this  implies  two  conditions:  (1)  That  the  active  causes  of 
caries  have  been  in  but  slight  evidence,  and  (2)  that  the  denture  is 
of  the  highest  order.  The  classes  of  dentures  which  escape  are  per- 
fectly formed  and  symmetrically  arranged  teeth,  in  the  mouths  of 
patients  who  lead  sanitary  lives  and  care  for  the  teeth,  who  masticate 
vigorously,  and  who  escape  other  diseases.  Very  filthy  dentures 
may  escape,  owing,  as  stated,  to  putrefaction      (See  page  271.) 

Caries  beginning  at  the  junction  of  the  cementum  and  enamel  of 
the  teeth  has  a  somewhat  different  clinical  history  from  that  noted 
when  its  occurrence  is  in  other  situations.  Its  progress  is  subject  to 
great  variations.  In  any  of  the  catarrhal  conditions  or  atrophic 
conditions  of  the  gum  which  lay  bare  the  neck  cementum,  caries 
usually  occurs.  This  is  usually  situated  at  the  middle  of  the  cervix 
in  the  cementum,  though  in  cases  of  recurrence  of  caries,  it  is  often 
at  the  labial  or  lingual  proximal  cervix.  It  occurs  also  as  a  process 
secondary  to  labial  abrasion  and  erosion  of  the  teeth  especially  at  the 
cervical  curve.  Teeth  affected  by  erosion,  however,  are  commonly 
exempt  from  dental  caries. 

The  Terminations  of  Caries.^After  the  pulp  is  exposed,  it  sooner 
or  later  becomes  inflamed  and  h}T)ertrophies  or  dies.  In  the  latter 
case  putrefaction  results,  which  for  a  time  may  exert  a  restraining 
influence  upon  decay,  but  not  for  a  long  time. 

Masses  of  food  freely  enter  the  pulp  cavity  and  caries  proceeds  in 
the  dentin  from  within  toward  the  periphery.  This  is  "secondary  or 
backward  caries"  of  dentin,  and  as  it  occurs  in  dentin  without  vital- 
ity, no  transparency  results  (Fig.  300).  Notwithstanding,  caries  at 
this  stage  proceeds  rather  slowly,  particularly  if  the  crown  be  much 
broken  down.  The  result  of  secondary  caries  is  a  hollowing  out  of 
dentin  of  the  root,  and  finally  a  decalcification  of  the  cementum, 
which  may  persist  for  some  time  as  a  thin,  elastic  wall.  Finally  this 
is  destroyed  either  at  the  occlusal  periphery,  or  caries  causes  pene- 
tration to  the  pericemental  tissue.  This  may  occur  laterally  or 
through  to  the  bifurcation  of  the  roots.    In  either  case  it  is  called 


SYSTEMIC  EFFECTS  FROM  CARIES 


299 


"perforation  by  caries."  Into  this  perforation  the  pericemental 
tissue  may  become  protruded  by  hypertrophy,  and  the  condition 
of  hyperplastic  or  fungous  gum  be  established.  Following  the 
breaking  down  of  the  crown,  the  blood  pressure  in  the  pericementum 
begins  an  extrusive  process,  the  pericementum  becomes  thickened, 
and  the  tooth  is  somewhat  loosened. 

Decay  of  the  root  face  and  interior,  and  breakage  of  the  cemental 
margins  proceed  eventually  with  the  extrusion,  until  finally  but 
a  small  discolored  bit  of  the  root  end  lies  upon  the  surface  of  the 
gum,  from  which  it  is  removed  by  some  slight  force  or  is  extracted. 

The  entire  process  of  caries  in  a  tooth  may  thus  extend  over  a 
period  of  from  ten  to  twenty  years. 

Fig.  307 


This  root  has  been  unsuspected  in  this  po.-iitiou  for  over  twenty  years;   a  small  blue 
spot  on  the  gum  overlying  it  being  the  only  indication. 

At  times  the  extrusive  force  pushes  a  root  up  sidewise,  particularly 
when  the  tooth  has  been  tipped  over  before  the  loss  of  the  crown. 
It  may  thus  be  retained  in  position  and  attached  upon  its  under  side 
for  some  time.  The  upper  side  may  be  polished  by  abrasion.  The 
exposed  end  of  a  root  undergoing  extrusion  is  also  sometimes  made 
smooth  by  abrasion.  A  bit  of  root  left  in  situ  after  breakage  during 
extraction  usually  undergoes  the  same  process  of  extrusion,  but  may 
not  decay  until  it  comes  under  oral  influences.  Usually  a  sinus  leads 
to  such  a  root,  but  the  gum  may  heal  over  it  (Fig.  307). 

Such  a  root  may  at  any  time  become  the  source  of  apical  abscess 
or  of  an  intractable  neuralgia,  the  cause  being  only  determinable 
by  radiography. 


SYSTEMIC  EFFECTS  FROM  CARIES. 

The  presence  of  cavities,  calculus,  and  pyorrhea  alveolaris  in  the 
mouth  all  tend  to  cause  infection  of  the  digestive  tract,  with  produc- 
tion of  inflammatory  (catarrhal)  disturbance,  and  to  cause  infection 
of  parts  in  close  association  with  the  teeth  as  well. 


300  DENTAL  CARIES 

Undoubted  cases  of  septic  intoxication  and  infection  from  decayed 
teeth  and  other  oral  conditions  have  been  reported,  the  connection 
having  been  shown  by  their  cure  after  removal  of  the  local  cause 
alone;  in  other  cases  the  parts  (as  the  stomach)  having  the  secondary 
infection  well  implanted,  have  required  special  treatment  in  addi- 
tion to  the  removal  of  the  primary  exciting  cause. ^  (See  Systemic 
Effects  of  Pyorrhea  Alveolaris.) 

The  loss  of  masticatory  efficiency  due  to  caries  or  the  associate 
pain  has  a  direct  bearing  upon  insalivation  of  food  and  upon  gastric 
digestion,  though  in  this  connection  bacterial  infection  may  play  a  part. 

Insomnia  and  a  variety  of  other  metabolic  ills  have  been  shown  to 
be  due  to  carious  teeth  and  the  sepsis  associated,  by  the  prompt  or 
gradual  recovery  upon  removal  of  the  teeth.  How  many  thousands 
of  individuals  suffer  from  partial  sepsis,  in  entire  ignorance  and 
possibly  without  actual  discomfort  can  only  be  conjectured.  It  is 
exceedingly  difficult  to  state  positively  that  a  metabolic  disorder  is 
due  to  the  state  of  the  mouth,  unless  a  microscopic  examination  from 
a  separate  locality  demonstrates  identical  bacteria  present.  Even 
then  the  therapeutic  test  must  decide.  Therefore  general  deductions 
must  govern  advice.  In  all  cases  it  is  wise  to  put  the  mouth  into  a 
hygienic  state  and,  if  necessary,  add  such  other  therapy  as  the 
systemic  condition  demands. 

School  children  who  suffer  much  from  caries  are  apt  to  be  less 
proficient  in  their  studies  than  normal  children,  the  effect  being 
probably  due  to  that  of  disturbed  digestion  upon  metabolism  and 
thus  upon  mentality  in  general.  Pain,  of  course,  is  a  direct  cause 
reducing  vitality  in  various  ways  and  causing  loss  of  time  and  atten- 
tion to  the  duty  of  study,  etc.  The  following  quotation  from  a 
tabulation^  shows  tj^ically  the  effect  of  dental  normality  upon 
mental  powers.  It  has  the  lowest  gain,  which  ranged  from  about 
32  to  about  918  per  cent. 

Beginning. 

Memory 66.65 

Spontaneous  association       .      .      .      .     74.2.5 

Addition 46.00 

Association  by  opposite        .      .      .      .     59 .  00 
Quickness  and  accuracy  of  perception      41.50 

Total  gain     ....     32.162  per  cent,  after  deducting  the  losses. 

1  Hunter:  International  Dental  Journal,  1899,  abstract  from  Transactions  of 
Odontological  Society  of  Great  Britain. 

In  an  address  at  McGill  University,  Montreal,  in  1910  (see  Dental  Brief,  November. 
1911).  Hunter  reaffirms  extensive  experience  with  gastritis,  septic  anemia,  septic 
endocarditis,  etc.,  as  the  result  of  oral  sepsis  in  which  decayed  roots  and  extensive 
dental  work,  (bridge,  etc.),  covering  septic  conditions  were  the  causes  and  which  were 
cured  by  removal  of  the  cause.  While  caries  was  not  separately  considered,  it  must 
be  seen  that  caries  is  largely  responsible,  for  the  inception  of  the  conditions  though 
pyorrhea  is  also  responsible. 

2  Dental  Brief,  1911.  Tabulation  of  the  Effects  of  Dental  Caries  on  the  Mental 
Powers  of  the  Dental  Class  in  Marion  School,  Cleveland,  Ohio. 


Per  cent,  of 

resent. 

Diffeience. 

gain  or  loss. 

66.6 

00.05 

00.07 

90.7 

16.50 

22.22 

63.0 

17.00 

36.95 

92.0 

33.00 

55.93 

60.5 

19.00 

45.78 

CHAPTER  X. 

DENTAL  CARIES:  DIAGNOSIS,  SYMPTOMS,  AND 
PROGNOSIS. 

DIAGNOSIS  OF  DENTAL  CARIES. 

The  diagnosis  of  dental  caries  is  made  through  both  objective  and 
subjective  symptoms.  The  signs  are  the  existence  of  cavities  and 
of  softened  areas,  directly  visible  or  made  evident  through  instru- 
mental means.  The  symptoms  are  pains  of  several  degrees  of  inten- 
sity. The  nature  and  intensity  of  the  pains  furnish  a  guide  to  the 
depth  of  the  carious  invasion,  and  but  an  indirect  indication  of  the 
location  of  the  disease. 

Diagnosis  by  Objective  Symptoms. — The  presence  of  the  markings 
of  superficial  decay,  decalcified  surfaces,  or  cavities  may  often  be 
detected  at  a  glance  or  be  seen  reflected  in  a  mouth  mirror.  Opacity 
of  enamel  is  usually  due  to  its  superficial  decalcification  or  caries 
beneath  it,  though  at  times  a  malformation  may  exist.  Sometimes 
a  zinc  phosphate  lining  vn\l  cause  an  opacity  resembling  backward 
caries  of  enamel.  The  discoloration  or  opacity  about  a  fissure  or 
occlusoproximal  or  bucco-  or  linguoproximal  surface  should  excite 
suspicion  of  caries.  In  the  routine  examination  for  cavities,  sharp, 
finely  pointed  explorers  bent  at  various  angles  are  to  be  passed  over 
all  the  sm'faces  of  the  teeth.  If  the  enamel  at  any  point  admit  the 
point  of  the  explorer,  caries  is  usually  present.  Fissures  are  some- 
times deceptive  in  this  respect.  A  good  rule  is  to  adjudge  the  pres- 
ence of  caries  when  the  point  catches  slightly  as  removed.  It  is  well 
to  remember  in  this  connection,  that  an  unsuspected  adjunct  fissure 
will  often  contain  beneath  it  caries  deeper  than  the  central  point 
judged  defective.  All  fillings  which  admit  of  penetration  between 
the  filling  and  margin  are  defective  often  permitting  much  caries 
under  the  filling.  This  is  especially  true  in  case  of  unextended 
occlusal  fissines  (see  also  Recm-rence  of  Caries). 

In  the  search  for  approximal  caries  great  care  is  required,  explorers 
with  very  short  points  being  often  necessary,  as  long  points  will  not 
turn  into  the  cavity  owing  to  the  close  contact.  The  ordinary  No.  7 
explorer  has  not  a  short  enough  tine.  Frequently  a  cavity  may 
only  be  discoverable  from  one  point  of  access,  so  that  the  approximal 

(301) 


302 


DENTAL  CARIES 


Fig.  308 


Fig.  309 


f  r 

si 

-3 


Explorer 
for  caries. 
(Jack.i) 


Dow  electric  lamp  for  mouth  illumination,  with 
reflectors.  Reflector  A  is  jointed  to  vary  the  angle  of 
reflection.  Reflector  B  is  for  illumination  of  the' 
fauces.  Reflector  C  is  for  lateral  illumination. 
(Jack.^)  Switchboards  usually  have  electric  lamp 
attachments. 

surfaces  should  be  examined  from  the  labial 
and  lingual  sides  and  also  from  the  occluso- 
proximal  aspect.  In  the  absence  of  evident 
cavities,  some  force  should  be  applied  to 
detect  softened  spots  of  enamel.  The 
catching  of  the  explorer  upon  both  teeth, 
after  it  has  passed  through  the  interspace, 
often  simulates  the  catch  in  a  cavity. 

Unwaxed  floss  silk  passed  over  carious 
surfaces  indicates  a  rough  surface  by  fray- 
ing. It  may,  however,  at  times  pass  readily 
over  a  cavity  easily  detected  by  instru- 
ments; so  that  it  is  not  absolutely  reliable 
as  a  test.  It  also  catches  on  a  rough  filling 
or  protruding  filling  margin.  If  the  short, 
sharp  pain  of  hypersensitive  dentin  is  pro- 
duced as  floss  passes  between  the  contact 
points  of  the  teeth,  either  a  masked  small 
cavity  or  a  loose  filling  should  be  suspected, 
and  if  not  found  with  the  explorer  or  light, 
a  wedge  should  be  introduced. 

The  strong  light  of  an  electric  mouth 
lamp  transmitted  through  the  teeth  exhibits 
a  cavity  as  an  opaque  spot  outlined  upon 
a  pinkish  background.  It  not  only  permits 
an  easy  diagnosis,  but  also  affords  evidence 
of  the  depth  of  penetration.  It  often  fails 
as  a  test  in  posterior  teeth.  Mechanical 
separators  or  wedges  are  at  times  necessary 


1  Aroerioau  Text-book  of  Operative  Dentistry. 


Ibi4. 


DIAGNOSIS  OF  DENTAL  CARIES  303 

to  press  apart  contiguous  teeth  sufficiently  to  admit  exploring 
instnunents. 

The  necks  of  the  teeth  should  be  examined  with  sharp  points,  to 
note  any  softness  of  the  tooth  tissues.  The  margins,  particularly 
the  cervical  and  neighboring  margins,  of  every  filling  should  be 
explored  to  test  the  integrity  of  the  junction  of  filling  and  tooth, 
or  any  excess  or  deficiency  of  filling  material.  Where  doubt  exists  at 
the  cervix  of  a  filling  it  should  be  remembered  that  caries  will  exhibit 
a  cervical  or  cavity  margin  and  a  filling  margin,  while  filling  excess 
will  have  but  one.  The  cervix  beneath  gold  crowns  and  the  joints 
of  dowelled  bandless  crowns  frequently  show  caries. 

The  examination  should  be  conducted  by  one  of  two  systematic 
methods.  In  one  method  the  occlusal  faces  of  all  the  teeth  are  first 
examined  in  one  survey,  then  the  proximal  surfaces,  and  lastly, 
the  buccal  and  lingual  surfaces  of  the  teeth.  In  the  other  method, 
every  portion  of  each  tooth  is  examined,  beginning  with  a  central 
incisor  or  terminal  molar,  before  passing  to  the  adjoining  tooth.  Any 
cavity  or  condition  found  should  be  noted  upon  a  diagram  for  refer- 
ence at  sittings.  This  is  preferably  done  at  once  so  it  will  not  be 
forgotten. 

Diagnosis  by  Subjective  Symptoms. — Complaints  by  patients 
that  cold  or  hot,  salt,  sweet,  or  acid  substances  taken  into  the  mouth 
cause  unlocalized  or  partly  localized  pain,  indicate  exposed  and 
hypersensitive  dentin  or  pulp  exposure.  Such  complaint  is  to  have 
due  consideration.  Slight  pain  has  also  been  produced  by  the 
passage  of  floss  over  a  minute  cavity  unexplorable  before  wedging, 
and  is  probably  due  to  compression  of  liquid  upon  dentine.  This 
symptom  at  the  cervix  of  a  tooth  indicates  hypersensitive  exposed 
dentin  which  may  or  may  not  be  carious. 

Pain  beginning  without  the  application  of  special  stimuli,  is  like- 
wise ordinarily  connected  with  caries  or  its  sequelae,  and  should  be 
taken  into  account. 

Pain  produced  upon  mastication  has  either  the  significance  of 
pressure  on  fibrils  or  pulp,  or  is  a  symptom  of  pericemental  irritation. 
Such  irritation  complained  of  by  patients  after  even  careful  attention 
is  not  uncommon  and  should  lead  to  rigid  search  for  masked  cavities, 
hypersensitive  occlusals  or  caries,  marginal  gum  irritation^  or  septic 
or  non-septic  pericementitis.  Much  harm  is  done  by  inefficient 
diagnosis  of  cavities  which  may  later  enlarge  and  expose  the  pulp. 
In  view  of  the  doubtful  success  of  root  canal  treatment  this  is  very 
important. 


304  DENTAL  CARIES 

PROGNOSIS  OF  CARIES. 

If  existing  caries  be  promptly  treated  in  youth  and  a  proper  sys- 
tematic prophylaxis  be  employed,  its  recurrence  during  youth  may 
be  largely  prevented.  At  about  adult  age  a  fair  degree  of  immunity 
may  be  expected.  In  the  absence  of  treatment  or  prophylaxis,  the 
exciting  causes  seem  to  become  very  active,  and  many  teeth  may  be 
lost  from  caries  or  by  reason  of  extraction  for  pulp  and  pericemental 
diseases.  Extraction  itself  brings  many  evils  in  its  train.  (See  Non- 
septic  Pericementitis.) 

Even  advanced  caries  may  be  checked  by  proper  filling  or  crown- 
ing, and  if  then  prophylaxis  receive  due  attention,  the  prognosis 
for  the  teeth. is  generally  good;  indeed,  it  seems  as  though  but  few 
conditions  exist  dependent  upon  caries  alone  except  in  advanced 
caries  of  roots  which  are  not  subject  to  correction  by  some  of  the 
means  within  the  resources  of  the  profession. 

HYPERSENSITIVITY  OF  DENTIN. 

Normal  dentin  has  a  varying  degree  of  sensitivity  as  shown  when 
sound  crowns  are  ground  or  sound  dentin  drilled,  therefore  only 
hypersensitivity  induced  by  some  abnormal  circumstance  can  be 
considered  a  pathological  entity. 

Therefore  it  may  be  defined  as  such  a  degree  of  fibrillar  sensi- 
tivity as  interferes  with  comfortable  instrumental  work  upon  dentin 
or  which  in  the  absence  of  dental  ministrations  causes  painful  symp- 
toms as  a  rule  reflected  about  neighboring  parts. 

Anatomical  Data. — The  dentinal  tubules  contain  the  prolongations 
of  the  odontoblasts  left  behind  in  their  progression  toward  the  physio- 
logical pulp  cavity  (dentin  being  developed  from  without  inward). 
These  so-called  dentinal  fibrils  extend  from  odontoblast  to  the  dento- 
enamel  junction  and  into  the  decussated  tubules  at  that  point. 
Mummery  of  late  has  seemed  to  show  that  very  fine  neurofibrils  pass 
"from  the  medullated  nerve  trunks  of  the  pulp  into  the  dentinal 
tubes,"  "  at  the  periphery  of  the  pulp  and  the  cornua.  The  medullated 
fibers  lose  their  medullary  sheath  and  neurilemma  and  the  axis 
cylinder  spreads  out  into  a  fan-shaped  expansion  of  neurofibrils 
which  enter  into  an  intricate  plexus  beneath  the  odontoblast  layer." 
From  this  plexus  neurofibrils  pass  to  form  a  network  around  and 
between  the  odontoblasts  without  forming  any  direct  communication 
with  them  while  other  larger  strands  of  the  neiu-ofibrils  pass  betw^een 
them  in  a  more  or  less  wavy  course  to  the  dentin  margin  and  enter 
the  dental  tubules. 


HYPERSENSITIVITY  OF  DENTIN  305 

Fig.  310  demonstrates  this.  It  is  only  fair  to  state  tliat  Hopewell- 
Smith^  has  denied  these  to  be  nerves  and  that  Hanazawa-  does  not 
make  any  claim  for  neurofibrils  in  the  tubules  as  the  result  of  his 
researches.  This  does  not  mean  that  Mummery's  technic  is  not 
correct  but  leaves  the  demonstration  as  yet  disputed. 

Hitherto  there  have  been  two  main  contentions: 

1.  That  the  nerves  ended  between  the  odontoblasts  (Retzius). 

2.  That  the  odontoblast  possesses  a  long  fiber  extending  back  into 
the  axis  cylinder  of  the  nerve  (Robertson). 

Fig.  310 


From  the  cornu  ot  the  pulp  of  a  fully  furmed  human  premolar,  a,  medullated  nerve 
bundle  dividing  (inclosing  the  transverse  section  of  bloodvessel) ;  d,  dentin.  Neuro- 
fibrils entering  the  tubules.      (Mummery,  Dental  Cosmos.) 

In  case  1  the  only  plausible  theory  of  pain  production  is  that  under 
irritation,  a  contraction  of  the  whole  cell  fibril  and  odontoblast 
occurs  (as  in  muscle  cells), ^  the  sensory  endings  being  pressed  because 
of  the  lateral  bulging  of  odontoblasts  {i.  e.  squeezed). 

In  case  2  the  fibrillar  connection  with  the  axis  cylinder  would  be 
pulled,  but  how  far  the  true  nerve  also  may  extend  into  the  odonto- 
blast and  dentinal  fibril  is  left  open  to  doubt. 

Any  of  the  above  histologies  would  account  for  pain  produced  by 
all  classes  of  irritants  by  direct  irritation  or  indirect  irritation  due  to 
contraction  of  the  whole  cell. 

The  theory  of  Gysi  that  a  wave-like  motion  is  set  up  due  to  incom- 
pressibility  of  the  water  or  the  theory  that  pain  is  due  to  compression 
does  not  seem  to  fit  chemical  or  thermal  irritants. 

1  Dental  Cosmos,  1916,  p.  421. 

2  Ibid.,  February  and  March,  1917. 

3  Black:  American  System  of  Dentistry. 
20 


306 


DENTAL  CARIES 


Normally  the  dentin  is  protected  from  external  agencies  by  the 
enamel,  and  in  the  early  stages  of  gmn  recession  by  the  cementum, 
though  it  has  been  shown  by  Choquet  that  the  enamel  may  be  over- 
lapped by  the  cementum  which  is  usual  or  may  overlap  it  or  they  may 
lie  edge  to  edge  or  the  dentin  may  be  uncovered  at  this  point. 

Thermal  stimuli  at  times  give  evidence  of  their  direct  effect  by 
producing  immediate  painful  sensations.  The  pulp  is  stimulated 
through  the  nerves  or  the  odontoblasts  and  their  relations  with  the 
terminals  of  sensory  nerves  in  the  pulp,  and  a  degree  of  vascular 

Fig.  311 


Diagram  of  enamel-rod  directions  and  tubule  curves.    From  a  photograph  of  a  bucco- 
lingual  section  of  a  superior  bicuspid.     (Noyes.) 


overfulness  occurs  which  may  be  denominated  mild  hyperemia.  The 
effect  of  these  reactions  is  to  cause  the  sensory  functions  of  the  pulp 
and  fibrils  to  become  somewhat  exalted,  and  it  therefore  becomes 
more  responsive  to  the  stimuli.  (See  Arterial  Hyperemia  of  the 
Pulp.) 

Apart  from  the  effect  of  thermal  changes,  other  substances  act  as 
irritants.  The  lactic  acid  and  other  bacterial  products  in  the  cavity 
of  decay,  without  doubt  play  a  part  in  exalting  the  irritability  of  the 
fibrils.    A  slightly  loosened  filling  holds  the  acid  in  contact,  as  such 


HYPERSENSITIVITY  OF  DENTIN  307 

cases  are  often  very  sensitive.  Salt,  sweet,  or  acid  substances  intro- 
duced into  the  mouth  are  also  evidently  irritant,  as  active  symptoms 
follow  their  application  to  hj-persensitive  dentin.  The  same  is  true 
of  acid  salts  as  zinc  chlorid. 

Mechanical  abrasion  or  erosion  may  irritate  the  fibrils,  or  at  least 
expose  them  to  the  action  of  other  irritants.  As  a  rule,  however,  the 
abraded  or  eroded  surfaces  are  protected  from  hypersensitivity  by 
the  process  of  eburnation.     (See  Transparent  Zone.) 

The  scraping  of  necks  of  teeth  with  scalers  sometimes  induces 
exposure  of  dentin.  Within  cavities  of  decay,  the  hypersensitivity 
is  greatest,  as  a  rule,  at  the  dentinal  periphery.  That  at  this  point 
the  branched  endings  of  the  tubules  present  a  greater  number  of 
fibrils  to  the  action  of  the  irritant  is  quite  evident  (Fig.  311),  which 
would  also  be  the  point  of  greatest  sensitivity  in  case  neiuofibrils  are 
present. 

In  cervical  hypersensitivity,  the  cementum  or  enamel  is  removed 
by  gum  recession,  abrasion,  erosion,  or  caries,  and  the  fibrils  are 
exposed.  The  presence  of  the  granular  layer  of  Tomes  in  this  situation 
and  the  possibility  of  this  layer  contaim'ng  the  expansions  of  the  fibrils, 
are  to  be  considered.     (Fig  313,  Gt.) 

In  certain  cases,  the  irritation  excited  by  the  touch  of  an  instrument 
to  dentin  adjacent  to  enamel  is  carried  to  the  pulp  by  anastomosing 
dentinal  fibrils.  This  was  proved  by  a  few  cases,  of  which  the  follow- 
ing is  an  extreme  one : 

In  a  central  incisor,  secondary  dentin  had  filled  a  portion  of  the 
pulp  cavity  (Fig.  312,  S  D).    Caries  had  subsequently  removed  the 
incisal  portion  of  this  secondary  growth  and 
also    the  dentin   containing  fibrils    leading  ^^°-  ^^^ 

from  the  pulp  cavity  to  the  middle  of  the 
incisal  edge.  The  application  of  an  ex- 
cavator to  dentin  in  the  incisal  portion  of 
the  cavity  (at  A),  the  fibrils  of  which  could 
have  no  direct  relation  with  the  pulp,  pro- 
duced flashes  of  pain.  This  was  unmistak- 
ably of  the  character  of  hypersensitive 
dentin. 

A  professional  friend  claimed  to  feel  sen- 
sitivity in  a  cervicolingual  cavity  of  a  molar,      J^^f'"''^-  t^^^^^^f  j^^  °f 

•^_  &  J  J       sensation  m  a  case  of  hyper- 

in  which  the  filaments  had  been  destroyed     sensitive  dentin:  s  D,  sec- 

by  suppuration  tor  one-third  of  tlie  length     Z^,^;/'  -"■'i^i".' 

of  the  canals.    If  his  contention  was  true,      grammatic.) 

the  sensation  must   have    been   conducted 

by  way  of  the  granular  layer  of  Tomes  to  the  level  of  the  pulp, 

and  thence  by  the  fibrils  to  its  substance  (Fig.  313). 


308 


DENTAL  CARIES 


Spots  of  cervical  hypersensitivity  have  been  occasionally  recorded 
as  occurring  in  teeth,  the  canals  of  which  have  been  filled. 

Head^  records  a  case  in  which  the  dentin  bounding  the  pulp  canal 
remained  hypersensitive  for  a  year  after  the  pulp  was  removed.  In 
this  connection  the  possibility  of  the  presence  of  a  vital  pulp  filament 
in  the  pulp  canal,  or  of  irritable  apical  tissue  receiving  the  impact  of 
liquid  forced  down  upon  it  by  a  canal  probe,  or  of  a  pericementum 

Fig.   313 


Two  fields  of  cementum,  showing  penetrating  fibers:    Gt.,  granular  layer  of  Tomes; 
C,  cementum  not  showing  fibers;  F.,  penetrating  fibers.     X  54  (about).    (Noyes.) 

irritable  to  touch  of  any  sort,  must  all  have  due  differentiation.  I 
have  never  seen  a  case  of  hypersensitivity  of  dentin  in  which  some 
filament  of  pulp  was  not  present,  in  at  least  a  part  of  the  tooth. 

Dentin  cannot  become  inflamed  in  the  ordinary  sense,  as  leukocytes 
cannot  enter  the  tubules;  nevertheless,  the  irritability  of  the  fibrils, 
like  that  of  other  protoplasm,  may  be  exalted  (or  lessened). 

1  Dental  Cosmos,  1899. 


HYPERSENSITIVITY  OF  DENTIN  309 

With  hypersensitivity  other  functions  are  increased,  and  in  con- 
ditions producing  a  constant  stimulation,  a  constructive  change  may 
occur  and  the  fibrils  form  tubular  substances  at  their  own  expense. 
(See  Transparent  Zone  and  Tubular  Calcification.) 

That  the  hypersensitivity  is  primarily,  as  a  rule,  a  disease  of  the 
tubular  contents  involved,  is  shown  by  the  fact  that  occasionally  of 
two  cavities  in  the  same  tooth,  one  will  present  a  hypersensitivity 
and  another  none;  again,  one  part  of  a  cavity  may  be  hypersensi- 
tive and  the  rest  not  so. 

Symptoms. — A  certain  degree  of  uneasiness  of  undefined  character 
may  at  times  be  noted  in  teeth  containing  cavities,  but,  as  a  rule, 
pain  other  than  pulp  pain  is  only  felt  upon  the  application  of  special 
stimuli.  Of  course,  the  presence  of  ferments,  acids,  etc.,  in  a  cavity 
are  real  stimuli. 

The  infiltration  of  acid,  salt,  or  sweet  substances  into  contact  with 
a  hypersensitive  surface  is  followed  by  a  wave  of  gnawing  pain, 
reflected  usually  along  the  course  of  contiguous  nerve  filaments. 
While  not  definitely  localized,  owing  to  the  fact  that  the  pulp  does 
not  possess  a  tactile  or  localizing  sense,  the  pain  may  usually  be 
referred  to  a  certain  part  of  the  mouth.  The  pressure  of  an  instru- 
ment upon  the  dentin  is  attended  by  a  flash  of  sharp  pain,  which 
continues  for  a  time,  but  lessens  if  the  contact  be  maintained.  In 
this  test  the  pain  is  localized  in  the  affected  tooth,  the  touch  of  the 
instrument  being  followed  by  a  recognition  of  position  by  the  tactile 
organ  of  the  tooth,  the  pericementum. 

Occasionally,  food  forced  by  mastication  against  a  hypersensitive 
surface,  such  as  due  to  abrasion  or  caries  in  a  crevice  or  cavity,  will 
produce  a  sharp  pain  subsiding  promptly,  and  which  may  not  be 
repeated  for  some  time.  The  mere  rubbing  together  of  opposing 
abraded  sm-faces  may  cause  the  symptom,  and  is  more  pronounced  if 
a  hard  substance,  as  grit,- gets  between  them. 

Cavities  dried  for  filling  usually  produce  a  steady  pain,  caused  by 
dryness  and  relieved  by  an  analgesic  or  by  filling. 

It  is  beyond  doubt  that  individuals  differ  as  to  the  degrees  of 
normal  dentinal  sensitivity;  the  dentin  of  one  person  may  be  cut 
freely  without  evidence  of  marked  pain;  in  another,  the  touch  of  an 
instrument  to  the  newly  exposed  dentin  is  productive  of  unbearable 
pain.  The  difference  in  degree  of  irritability  is  manifested  in  another 
manner:  If  a  mild  sedative — for  example,  oil  of  cloves  or  an  obtun- 
dent— be  applied  to  the  hypersensitive  dentin  of  one  person,  it  may 
remove  the  distressing  symptoms,  but  with  others  it  may  be  necessary 
to  employ  the  most  extreme  measures  to  reduce  in  any  degree  the 
hypersensitivity.     In  some  cases,  the  exposure  of  dentin  about  the 


310 


DENTAL  CARIES 


necks  of  teeth  may  induce  such  an  unbearable  local  pain  or  neuralgic 
condition  as  to  positively  demand  relief. 

In  a  few  cases  enamel  has  exhibited  sensitivity.  In  one  case  the 
effort  to  open  sound  fissures  about  a  cavity  for  prevention  excited 
sharp  pain,  ceasing  upon  removal  of  the  instrument.  The  patient 
was,  however,  a  sufferer  from  insomnia,  and  from  the  effects  of 
morphine  taken  for  it,  and  her  dentin  was  exquisitely  sensitive.  This 
patient  seen  again  after  a  lapse  of  many  years  had  scarcely  any  sen- 
sitivity. The  same  phenomenon  of  enamel  sensitivity  is  to  be  noted 
in  one  of  her  children. 


Fig.  314 


Fig.  315 


The  Teter  nitrous  oxide  and 
oxygen  apparatus  on  apparatus 
stand. 


Gregg  nasal  inhaler. 


In  another  patient,  the  side  of  the  enamel  exposed  by  a  cavity  in  a 
molar  analogous  to  that  in  Fig.  312  gave  flashes  of  pain  when  touched 
with  an  excavator  point,  though  no  evident  direct  path  of  trans- 
mission to  the  pulp  could  be  seen.  Caush's  tubes  and  indirect  trans- 
mission seem  the  only  basis  of  explanation  (Figs.  124  and  311). 

There  is  a  pseudohypersensitivity  of  enamel  in  some  cases,  due  to 
apprehension.  The  patients  can  be  ridiculed  out  of  the  idea  by 
demonstrating  its  absurdity,  as,  for  example,  by  touching  a  cusp 


HYPERSENSITIVITY  OF  DEXTIX  311 

and  then  showing  them  the  part  touched-    Pericemental  irritabihty 
at  times  must  also  be  excluded. 

There  can  be  no  question  that  systemic,  nervous  irritability  from 
any  cause  aggravates  the  phenomenon  of  hypersensitivity,  though 
whether  it  can  make  dentin  more  sensitive,  or  whether  the  patient 
is  less  able  to  endure  pain,  is  not  clear. 

The  general  perceptivity  of  the  individual  seems  to  play  a  part, 
and  even  apparently  normal  dentin  may  be  exquisitely  hypersen- 
sitive. Again,  pain  produced  in  excavation  may  be  due  to  the 
character  of  the  manipulation,  hea\^'  continued  burring  producing 
heat;  lighter  touches  may  excavate  equally  well,  but  produce  much 
less  pain.  The  dulness  of  the  excavator  or  bm*  has  a  similar  effect. 
The  presence  of  some  sensitivity  of  dentin  on  cutting  is  a  positive 
sign  of  pulp  vitality. 

The  total  absence  of  dentinal  sensitivity  should  cause  suspicion  of 
pulp  death  but  is  not  proof  of  it  and  fm-ther  tests  should  be  made. 

Diagnosis.- — In  the  diagnosis  the  above  characteristic  symptoms 
are  to  be  considered.  The  decisive  test  is  made  by  pressing  an 
instrument  upon  the  suspected  surface  or  cutting  with  a  bur,  when 
the  characteristic  pain  is  produced,  subsiding  upon  or  shortly  after 
removal  of  the  contact. 

Upon  the  pulpal  wall  of  deep  cavities  doubt  may  exist  as  to  whether 
the  pain  is  due  to  pulp  irritation. 

A  suspected  exposure  may  be  differentiated  by  the  localization  of 
the  pain  upon  touch,  to  a  point  corresponding  to  the  pulp  horn  or 
pulp  body,  or  by  the  point  catching  in  the  exposure.  Hypersensitive 
dentin  will  be  more  generally  distributed  or  occur  at  points  at  which 
exposure  is  impossible.  Pulp  abnormality  or  approach  may  be 
detected  by  means  of  a  drop  of  cool  water  or  a  blast  of  cool  air  from 
a  sjTinge,  though  this  if  obtained  may  generally  be  disregarded  in 
shallow^  ca^dties.  (See  H^^eremia  of  the  Pulp.)  Dentin  may  react 
severely  when  fillings  are  pressed  into  even  shallow  cavities,  some- 
times this  is  only  momentary;  occasionally  the  reaction  continues  for 
a  time.  Sometimes  it  causes  a  pulp  hyperemia,  usually  passing  away. 
Rarely  the  immediate  reaction  may  be  very  severe  necessitating  the 
removal  of  the  filling  at  once.  Pain  following  drying  may  be  dis- 
regarded as  may  that  produced  by  the  acid  of  cements.  These 
remarks  apply  in  cavities  up  to  and  including  those  classed  as  deeply 
seated.  In  case  of  almost  exposed  pulp  the  immediate  reactions  are 
more  Hkely  to  be  severe  and  the  ultimate  reactions  are  more  likely  to 
be  pulpal.     (See  Arterial  Hyperemia  of  Pulp.) 

Treatment. — The  methods  of  treatment  which  have  been  followed 
for  the  relief  of  hypersensitivity  of  dentin,  and  the  induction  of  such 


312  DENTAL  CARIES 

a  degree  of  analgesia  as  will  permit  the  necessary  cutting  of  dentin, 
may  be  divided  into  general  and  local. 

General  Remedies. — The  general  remedies  employed  are  those 
which  abolish  or  lessen  the  perceptive  function  in  the  centers  of  the 
fifth  pair  of  nerves,  or  which  reduce  hyperirritability  of  the  nervous 
system.  Either  general  anesthesia  or  general  anodynes  are  em- 
ployed to  lessen  perception.  The  inhalation  of  a  few  whiffs  of  chloro- 
form or  ethylic  ether  lessens  the  perception  of  pain,  or  a  mixture  of 
chloroform,  ether,  and  alcohol  may  be  used.  Chloroform  is  usually 
avoided  in  this  connection  on  account  of  its  dangers  when  used  in 
the  sitting  position.  Slight  etherization,  the  inhalation  being  carried 
only  to  the  benumbing  point,  affords  marked  relief  from  the 
pain  incidental  to  the  cutting  of  hypersensitive  dentin.  While  true 
it  is  rarely  employed.  Nitrous  oxide  and  oxygen  administered  to 
the  point  at  which  "analgesia"  without  anesthesia  occurs  is  a 
method  now  much  employed.  A  special  nasal  inhaler  admits  the 
gases  in  various  combinations,  the  mixture  of  the  prepared  gases 
being  made  in  the  mixing  chamber  of  the  apparatus,  after  the  gases 
leave  the  cylinders.^ 

It  is  preferable  that  the  gases  be  warmed  to  avoid  the  irritation 
of  the  lungs  by  the  cold  gases,  though  for  short  operations  this  is 
often  omitted. 

Rebreathing  the  carbon  dioxid  and  gases  exhaled  is  also  advocated 
as  a  respiratory  stimulant  and  for  economy.  In  view  of  hypersensi- 
tive dentin  the  method  is  now  routine  for  cavity  preparation  and 
for  the  grinding  of  teeth  with  living  pulps,  for  abutments  or  for  other 
work  involving  a  reasonable  amount  of  pain.  It  is  not  generally 
useful  for  pulp  removal  unless  complete  anesthesia  is  induced.  The 
method  has  various  dangers  which,  while  not  preventing  its  use  in 
careful  hands,  renders  it  not  to  be  carelessly  employed.  Aimoyances 
or  occasional  failure  occur.  Fear  is  apt  to  contra-indicate  its  use  in 
children. 

The  element  of  suggestion  and  confidence  on  the  part  of  the 
operator  seems  to  play  an  important  part  in  the  success  of  the  anal- 
gesia, though  the  analgesia  is  not  dependent  upon  it.  The  patient 
is  able  to  cooperate  with  the  operator,  not  having  lost  consciousness. 
In  the  practical  application  of  the  mixed  gases,  the  apparatus  is  first 
set  as  to  constancy  of  flow  of  both  gases,  the  proportion  of  95  per 
cent.  N2O  and  5  per  cent.  O  being  first  applied,  until  the  patient 
reaches  a  condition  of  somnolence,  of  which  he  informs  the  operator. 
The  proportions  are  now  changed  until  approximately  80  per  cent. 

1  For  details  of  apparatus  and  application  read  C.  K.  Teter,  Dental  Cosnaos,  August 
1912;  W.  C.  Teter,  Dental  Brief,  August,  1911;  A.  E.  Smith,  Items  of  Interest, 
December,  1913;  Harold  B.  Clark,  Items  of  Interest,  April,  1914,  and  others. 


HYPERSENSITIVITY  OF  DENTIN  313 

N2O  and  20  per  cent.  O  are  being  given,  though  this  proportion 
is  variable.  The  patient  is  instructed  to  breathe  through  the  nose  if 
pain  is  felt,  thus  obtaining  deeper  analgesia.  Conversely,  as  work  is 
not  being  done,  he  may  breathe  through  the  mouth.  If  greater  depth 
of  anesthesia  is  required,  the  exhaling  valve  which  ordinarily  vents 
the  expirations  is  adjusted  and  the  patient  then  rebreathes  the 
gases  together  with  his  own  carbon  dioxid,  M^hich  further  stimulates 
respiration,  and  gradually  passes  into  anesthesia,  especially,  if  ^the 
percentage  of  oxj^gen  be  decreased.  Without  rebreathing,  95  per 
cent.  N2O  and  5  per  cent.  0  will  produce  anesthesia.  The  amount  of 
rebreathing  is  controlled  by  a  vah'e  and  rebreathing  bag.  Somnoform 
(mainly  ethyl  chlorid)  has  also  been  used  with  a  special  inhaler 
(De  Ford  or  Starck)  to  produce  analgesia. 

The  administration  of  general  anodynes,  particularly  the  com- 
bination of  morphin  and  atropin,  has  been  found  useful  in  this  field. 

I^ — Morphinse  sulph gr.  | 

Atropinae  sulph gr.  jA^ 

M.  et  ft.  pil.  No.  1. 

Sig. — To  be  taken  one-half  hour  before  operation. 

Flagg  noted  that  blondes  bear  morphin  sulphate  better  than 
brunettes;  particularly  are  nervobilious  and  bilionervous  patients 
idiosyncratically  opposed  to  its  use,  the  physiological  action  of  the 
drug  being  reversed  or  the  after-effects  being  pronounced.  Patients 
having  dark  hair  and  blue  eyes  may  be  expected  to  be  thus  idio- 
syncratic. For  them,  he  recommended  morphin  bimeconate  solution 
in  doses  equivalent  to  |  grain  of  the  salt,  to  be  taken  one  the  evening 
before,  and  the  other  before  the  operation. 

Chloral  in  5  or  10  grain  doses,  administered  in  water  before  the 
operation,  has  a  quieting  effect  upon  the  nervous  system.  Ambler^ 
has  suggested  the  use  of  from  10  to  20  drops  of  fluidextract  of  piscidia 
erythrina,  to  be  administered  about  ten  minutes  before  operating. 
Drowsiness  may  be  expected.  Phenobromate,  10  grains,  before 
operation,  or  15  grains  for  any  great  pain,  may  be  administered  in  a 
copious  draught  of  water. 

For  the  reduction  of  excitement  and  nervousness  in  anticipation 
of  dental  operation,  bromural,  5  grs.,  ordinarily  to  be  administered 
while  waiting,  or  10  grs.  in  unusual  cases,  is  highly  recommended  for 
this  purpose  by  Hecker.^  It  is  also  useful  in  insomnia,  and  its 
associated  hyperesthesia.  Quinine  sulphate,  5  grains  a  half-hour 
before  operation,  or  better  if  preceded  by  another  dose  the  day 
before  it  is  to  be  used.  The  bromids,  either  of  sodium,  potassium  or 
ammonium  or  triple  bromid,  may  be  taken  the  day  previous  "and  just 
before  coming  to  the  office.    The  dose  may  be  from  5  to  15  grains. 

1  Dental  Cosmos.,  1901.  2  Ibid.,  1909,  p.  844. 


314  Mntal  caries 

Hyoscyamin  hydrobromate,  eV  grain,  will  be  useful  in  those  cases 
which  are  associated  with  muscular  spasm  or  hysteria. 

The  coal-tar  derivatives,  phenacetin,  acetanilid,  and  others,  are 
occasionally  eflScient.  The  preparation  known  as  antikamnia  (said 
to  be  a  combination  of  acetanilid,  caffein  citrate,  and  sodium  bicar- 
bonate) and  ammonol  (acetanilid  and  ammonium  carbonate,  equal 
parts)  are  to  be  preferred  in  this  connection.  The  dose  of  the  latter 
two  is  10  grains,  administered  one-half  hour  before  operation. 

The  writer  has  one  patient  who  obtains  a  sufRcient  analgesia  for  the 
excavation  of  very  sensitive  cavities  by  taking  small  doses  of  whisky. 
Rapid  breathing  until  the  ''head  swims"  according  to  Bonwill's  plan 
has  been  of  use  in  some  cases. 

The  induction  of  the  hypnotic  state  belongs  in  the  category  of 
means  acting  upon  the  nerve  centers.  The  use  of  the  ordinary  sug- 
gestion that  the  work  will  not  be  unduly  painful,  considerate  treat- 
ment, patience,  and  the  employment  of  remedies  all  have  a  calming 
influence,  permitting  relaxation  upon  the  part  of  the  patient,  who, 
if  "keyed  up"  to  expect  great  pain,  will  expect  and  feel  unduly. 

Conductive  Anesthesia. — ^Midway  betw^een  truly  systemic  and 
purely  local  measures  lies  the  method  of  anesthetizing  the  nerve  tract 
leading  from  a  tooth  to  the  brain.  This  is  truly  a  "nerve  blocking" 
in  which  the  nerve  is  rendered  incapable  of  performing  its  function 
of  sensation.  Two  methods  are  employed:  (1)  An  injection  into  gum 
tissue  intended  to  cause  the  anesthetic  to  reach  the  sensory  nerve  in 
the  apical  tissue  after  passage  through  the  bone.  This  is  called  from 
the  site  of  injection  "mucous  anesthesia"  also  "infiltration  anesthesia." 

2.  When  the  injection  is  made  at  some  more  distant  portion  of  the 
nerve  (along  the  course  of  its  main  trunk)  it  is  called  "conductive 
anesthesia,"  though  the  term  "nerve  blocking"  would  be  just  as 
applicable.  It  is  plain  that  there  is  no  distinction  in  principle  in  any 
of  the  forms  of  local  anesthesia.  It  is  simply  a  question  of  the  site 
of  application,  pulp,  apical  nerve  or  nerve  trmik;  in  all  a  temporary 
sensory  paralysis  is  produced.  When  the  hypodermic  or  deep  injec- 
tions are  made  the  following  conditions  are  necessary: 

1.  A  competent  armamentarium. 

2.  Complete  asepsis. 

3.  An  effective,  safe  and  isotonic  anesthetic  solution. 

4.  Correct  technic,  which  involves  a  knowledge  of  the  anatomy 

of  the  part. 

5.  A  sufficient  allowance  of  time  for  infiltration  of  the  anesthetic. 
1.  The  necessary  special  instruments  are  a  sterilizable  syringe, 

all  metal,  Fischer,  Tagg  Record,  etc.,  a  short  iridio-platinmn  needle 
(23  mm.)  and  a  long  one  (42  mm.)  (Fig.  316.)  These  are  to  be  kept 
in  good  order  and  should  never  be  used  if  they  leak  back  aromid  the 


HYPERSENSITIVITY  OF  DENTIN 


315 


Fig.  316 


plunger.  x\ll  hubs  and  needles  should  fit  tightly  and  iiot  leak  inider 
considerable  pressure.  For  conductive  anesthesia  iridio-platinum 
needles  are  used;  but,  if  preferred,  steel  needles  may  be  used,  but 
requii'e  more  time  for  care,  which  increases 
the  eventual  cost,  and  the}'  have  disadvan- 
tage in  that  the}'  cannot  be  flamed,  and  are 
said  to  break  more  readily.  In  mucous 
anesthesia  the  tough  gum  tissue  renders 
fine,  short,  steel  needles  advisable  (28 
gauge,  J  inch).  The  hub  provided  shortens 
the  needle  exposed  to  a  correct  length  for 
each  form  of  anesthesia. 

2.  Asepsis  is  maintainable  by  glowing 
the  platinum  needle  in  a  Bunsen  or  alcohol 
flame  before  and  after  the  injection,  keep- 
ing the  mounted  s}'ringe  and  extra  needle 
in  an  antiseptic  solution  (alcohol  2  parts, 
gh'cerin  1  part)  in  an  air-tight  jar  or  a 
large  Petri  dish.  When  using,  place  syringe 
under  the  hot  water  tap  to  wash  oft'  the 
alcohol;  dip  in  the  sterilizer  containing 
boiling  distilled  water  and  draw  it  full  of 
the  water  and  eject  three  times  to  clear 
the  interior.  The  needle  is  then  flamed 
and  the  anesthetic  solution  drawn  in.  The 
syringe  is  then  placed  in  the  folds  of  an 
aseptic  towel  and  the  needle  should  touch 
nothing  until  the  injection  is  made.  The 
field  of  operation  is  wiped  off  and  gently 
scrubbed  with  iodin  tincture  (for  alterna- 
tive see  Asepsis)  and  the  hands  are  to  be 
sterilized  (see  Aepsis).  Blimi^  suggests  as  a 
local  analgesic  and  antiseptic  a  solution 
containing  equal  parts  of  tincture  of  aconite 
and  iodin  and  absolute  alcohol.  The  solu- 
tion is  considered  later. 

3.  For  extractions  done  often  each  day 
a  special  solution  may  be  made  for  a  suitable  period  (see  works  on 
dental  materia  medica).  For  the  present  purposes  the  solution  is 
now  usually  made  as  needed  from  a  tablet  (E)  of  no^'ocain  suprarenin. 

I^ — Novocain 0.02        gram 

Synthetic  suprarenin 0.00005  gram 

"Procaine"  is  the  official  name  of  the  U.  S.  Government  for  para-amino-benzyl- 
diethyl-amino-ethanol  formerly  made  in  Germany  as  novocain  and  identical  with  it. 


Syringe  mounted  with 
Schimmel  hub  C  and  42  mm. 
needle  for  injection  at  infra- 
orbital foramen  and  mandib- 
ular foramen.     (Fischer.) 


1  Items  of  interest,  1915,  p.  648. 


316 


DENTAL  CARIES 


This  keeps  indefinitely,  though  spoiled  if  found  pink  in  color.  (Tablet 
T  contains  less  suprarenin.)  This  is  added  to  1  mil.  (c.c.)  of  the  follow- 
ing solvent  and  vehicle: 

I^ — Calcium  chlorid 0 .  04  gram 

Potassium  chlorid 0.02" 

Sodium  chlorid 0.05     " 

Distilled  water  (sterile) 100.0    mils.  (c.c.  or  grams) 

This  makes  1  mil.  (c.c.)  of  a  2  per  cent,  solution,  therefore  one 
tablet  should  be  added  to  each  mil.  of  solvent  to  make  the  desired 
quantity.  To  make  a  1  per  cent,  solution  add  one  "E"  tablet  to 
each  2  mils,  of  solvent  and  for  a  1.5  per  cent,  solution  add  one  to 
each  1.5  mil.  of  solvent. 

Fig.  317 


Posterior  view  of  position  of  needle  in  mandibular  anesthesia:  1,  external  oblique 
line;  2,  internal  obhque  line;  3,  position  of  needle  at  superior  margin  of  lingula;  4, 
most  suitable  length  of  needle  behind  lingula  (a  further  advancement  would  result  in 
failure);  6,  position  of  needle,  1  cm.  above  level  of  masticating  surfaces  of  molars;  7, 
lingula;  8,  inferior  dental  foramen.      (Fischer.) 

Fischer  claims  that  the  calcium  chlorid  acts  as  a  heart  activator 
and  offers  evidence  in  proof  of  its  value  as  against  a  sterile  physio- 
logical sodium  chlorid  solution  alone  which,  however,  may  be  used^ 
and  is  advised  by  Prinz.  The  above  solvent  may  be  prepared  from 
purchasable  "Ringer  tablets,"  one  being  added  to  each  10  mils,  of 
sterile  distilled  water  and  the  whole  boiled  for  ten  to  twenty  minutes 
in  the  dropper  bottle  (with  cotton  in  the  mouth)  by  setting  on  a  cloth 
in  boiling  water  in  a  pan.    The  dropping  bottle  may  be  kept  practi- 


'  Journal  of  Allied  Dental  Societies,  September,  1914,  p.  416. 


HYPERSENSITIVITY  OF  DENTIN  317 

cally  sterile  by  inverting  a  small  measuring  glass  over  it  and  placing 
over  the  whole  a  bell  jar  or  a  ''cozy." 

When  making  up  the  anesthetic  solution,  drop  the  reqviired  amount 
into  a  porcelain  "Novocain  dissolver"  which  is  graduated  in  mils., 
boil  and  add  the  required  number  of  E  tablets  and  gently  heat  again 
until  dissolved.  It  is  placed  in  the  fold  of  the  aseptic  towel  until  the 
syringe  is  prepared.  The  order  may  be  reversed.  The  stock  bottle 
of  distilled  water  should  have  its  stopper  and  neck  covered  with  a 
wad  of  cotton  held  by  a  rubber  band.  It  is  wise  to  occasionally  boil 
it.  Usually  2  mils,  of  solution  suffice  for  even  conductive  anesthesia. 
Fischer^  places  20  mils,  of  a  2  per  cent,  solution  as  the  maximum 
dosage,  but  states  that  in  surgery  200  mils,  of  a  1.5  per  cent,  solution 
has  been  used  in  Europe  with  impunity.  It  would  be  wise  to  keep 
well  within  Fischer's  figures,  at  say  two  "E"  tablets  at  one  sitting. 
When  mucous  anesthesia  is  employed,  the  solution  is  injected  into 
and  beneath  the  periosteum,  both  buccally  and  lingually,  as  nearly 
over  the  apex  of  the  root  as  possible  and  gently  massaged  into  the 
bone.  For  single-rooted  teeth  a  buccal  injection  may  be  sufficient. 
The  25-m.  needle  is  employed.  About  ten  minutes  are  required  to 
produce  satisfactory  pulp  anesthesia.  Fischer-  emphasizes  the  follow- 
ing conditions  for  success  in  mucous  anesthesia: 

1.  The  application  of  a  stasis  bandage  slightly  compressing  the 
carotid  artery  and  the  veins  of  the  neck,  to  help  retain  the  anesthetic, 
and  prevent  cerebral  anemia. 

2.  The  periosteum,  not  the  submucous  tissue  must  be  infiltrated. 

3.  One  injection  to  be  made  on  each  side  of  the  teeth.  The  fewer 
injections  the  better  the  effect. 

4.  The  part  must  be  sterilized  with  tincture  of  iodin  and  the 
sterile  needle  must  have  its  orifice  faced  toward  the  bone. 

5.  Slow,  moderately  strong  pressure  during  the  injection. 

6.  The  point  of  injection  must  be  compressed  with  the  finger, 
after  the  needle  is  withdrawn  to  allow  diffusion  of  the  anesthetic. 

In  conductive  anesthesia,  the  anesthetic  is  injected  into  the  tissue 
contiguous  to  a  nerve  trunk.  The  fechnic  for  uyyer  second  bicvspid 
to  third  mclar  controlled  by  the  posterior  superior  dental  branches 
of  the  second  division  of  the  fifth  nerve  (known  as  the  maxillary 
tuberosity  injection),  is  as  follows: 

Palpate  the  molar  process  with  mouth  half -open  with  the  fore- 
finger and  raise  the  cheek  with  it  and  the  thumb.  Insert  the  42-mm. 
needle  with  the  openmg  toward  the  bone  into  the  loose  tissue  at 
the  reflex  of  the  mucous  membrane  just  posterior  to  the  root  of  the 

'  Journal  of  Allied  Dental  Societies,  1914,  p.  420. 
^  Local  Anesthesia  in  Dentistry. 


318 


DENTAL  CARIES 


upper  first  molar  Fig.  318-^.  Follow  the  surface  of  the  bone  through 
loose  tissue  at  an  angle  of  about  45  degrees  upward  and  backward 
until  the  needle  is  inserted  to  the  hub.  Injection  is  made  in  one  of 
two  ways: 

1.  Just  after  penetration  by  the  needle  a  portion  of  solution  is 
injected  and  the  injection  repeated  as  the  needle  is  advanced. 

2.  The  better  method,  allowing  the  pen  grasp  of  the  syringe  through- 
out, is  to  insert  the  needle  to  its  full  depth  as  this  is  practically  pain- 
less after  the  mucosa  has  been  penetrated.     Injection  of  half  of  the 


Fig. 

318 

7-Z;- 

// 

i 

m 

J- 

;     i 

f 

'     \ 

t  . 

!,>:r 

J,  J 

XI 

Feints  of  injection  in  the  maxilla  in  mucous  and  conductive  anesthesia.  U,  line  of 
reflection  cf  mucous  membrane:  1,  injection  tor  upper  right  central  incisor;  2,  for 
upper  right  lateral  incisor;  3,  for  conductive  anesthesia  cf  upper  right  lateral,  canine, 
and  first  bicuspid,  the  needle  to  be  advanced  to  the  infraorbital  foramen;  4.  ^ov  up- 
per right  second  bicuspid;  5,  for  upper  right  first  molar;  6,  conductive  anethesia  at 
maxillary  tuberosity  for  upper  right  first,  second,  and  third  molars;  7,  conductive 
anesthesia  for  upper  right  third  molar.      (Fischer.) 


2  c.c.  of  solution  in  the  syringe  is  then  made  for  the  higher  branch 
(Fig.  318-6'.r)  and  the  syringe  partly  withdrawn  and  the  balance  in- 
jected for  the  lower  branches.  This  injection  suffices  for  pulp  and 
dentin  work.  For  extractions  an  injection  must  be  made  about 
one-half  inch  above  the  gingival  margin  of  the  thhd  molar  into  the 
palatal  mucosa  and  to  the  periosteum  to  infiltrate  the  anterior 
palatine  nerve  Fig.  319.     Ten  minutes  is  about  the  waiting  period. 

Technic  for  Upper  Central  Incisor  to  First  Bicuspid  (known  as 
the  infraorbital  injection.)  This  region  is  controlled  by  branches 
from  the  infraorbital  nerve  which  must  be  anesthetized  just  withm 
the  border  of  the  infraorbital  foramen.  To  do  this  place  the  fore- 
finger at  the  inner  canthus  of  the  eye,  draw  it  down  and  outward 


HYPERSENSITIVITY  OF  DENTIN 


319 


along  the  border  of  the  orbit  to  a  point  0.5  cm.  below  it  and  about 
the  same  distance  from  the  border  of  the  malar  process.  This  spot 
is  somewhat  more  sensitive  than  others.  It  should  then  be  almost 
directly  over  the  first  bicuspid  and  be  upon  the  location  of  the  infra- 
orbital foramen.  The  lip  is  raised  with  the  thumb  and  the  needle 
inserted  somewhat  away  from  the  bone  into  the  mucosa  reflex 
just  posterior  to  the  cuspid  tooth.     It  should  penetrate  to  a  point 

Fig.  319 


Posterior  pal- 
atine fo/a- 
meti 


:;jp7 


Bony  surface  of  palate.  The  crosses  indicate  the  points  of  injection  for  mucous 
anesthesia;  these  at  the  palatal  of  the  third  molars  are  the  sites  for  blocking  of  the 
anterior  palatine  nerve  for  extractions  and  surgery  of  alveoli;  for  blocking  of  naso- 
palatine nerve  inject  one-fourth  inch  above  the  lateral  incisor  of  respective  side. 
(Fischer.) 


just  beneath  the  finger  tip.  Somewhat  forcible  injection  is  then 
made  beneath  the  finger  and  from  0.5  to  1  c.c.  of  solution  is 
injected  and  well  massaged  into  the  foramen  to  anesthetize  the 
anterior  superior  dental  nerves.  This  serves  for  pulp  and  dentin 
work,  but  for  extraction  an  injection  must  be  made  one-quarter 
inch  above  the  gingival  margin  of  the  lateral  of  the  respective  side 
to  infiltrate  the  naso-palatine  nerve  at  the  neighborhood  of  its 
foramen  (Scarpa's).     Ten  minutes  is  the  waiting  period. 


320  DENTAL  CARIES 

Technic  for  the  Mandibular  Injection. — This  accomplishes  anes- 
thesia of  the  pulps  of  teeth,  the  bone  and  mucous  membrane  of 
one  side  of  the  mandible  by  infiltration  of  the  inferior  dental  branch 
of  the  fifth  nerve  at  its  entrance  into  the  inferior  dental  canal  and 
by  infiltration  of  the  lingual  nerve  at  a  point  anterior  to  the  location. 
One  injection  only  need  be  made  for  pulp  and  extraction  work.  Between 
the  internal  oblique  line  of  the  ramus  and  the  external  oblique  line  and 
back  of  the  last  molar  lies  a  grooved  depression  known  as  the  retro- 
molar  triangle  (Fig.  317-/?).  This  should  be  palpated  from  the  front  on 
the  right  side  and  from  around  the  head  on  the  left  side  with  the  tip 
of  the  left  forefinger.  The  nail  should  lie  at  the  internal  oblique  line. 
The  middle  of  the  finger-nail  is  the  landmark  for  insertion  of  the 
needle.  The  s^'ringe  barrel  is  laid  across  the  contact  between  the 
canine  and  first  bicuspid  of  the  opposite  side  and  the  needle  inserted 
close  to  the  edge  and  needle  of  the  finger-nail.  Some  prefer  to 
enter  straight,  find  the  internal  oblique  line  and  pass  it,  then 
to  throw  the  syringe  to  the  opposite  side.  This  should  be  about 
1  cm.  above  the  occlusal  of  the  last  molar.  The  needle  is  inserted 
into  the  mucosa,  carried  to  the  bone  and  then  with  a  minute 
withdrawal  to  escape  the  periosteum  is  carried  along  the  soft  tissue 
close  to  the  bone  and  yet  away  from  periosteum.  If  the  needle 
catch  a  protuberance  it  should  be  slightly  withdrawn  and  carefully 
advanced  around  it  (this  to  avoid  breaking  the  needle) .  This  general 
mode  of  advance  is  made  until  the  needle  is  one-fourth  inserted, 
when  a  small  portion  of  solution  is  deposited  for  anesthesia  of  the 
lingual  nerve.  The  advance  is  then  continued  to  the  full  depth 
to  the  hub  of  the  42  mm.  needle  (about  25  mm.  of  needle).  The 
needle  point  then  lies  in  a  safe  position  in  the  region  near  the  nerve 
(Fig.  317-4).  Changing  the  hand  to  the  injecting  position  the  balance 
of  the  solution  is  injected.  From  ten  to  twenty  minutes  is  the 
waiting  period  for  the  mandibular  injection.  Occasionally  a  mucous 
anesthesia  is  required  over  the  special  tooth. 

^Yhile  the  time  required  for  anesthesia  is  about  ten  minutes  in 
the  maxilla  and  twenty  in  the  mandible,  one  may  test  with  a  bur 
(or  lancet  on  the  gum)  for  a  satisfactory  result  before  this  time. 
Occasionally  a  pulp  is  not  anesthetized  at  all  while  other  tissues 
seem  to  be  and  occasionally  an  apical  portion  only  is  sensitive. 
The  writer  when  having  a  tooth  extracted  distinctly  felt  the  burn 
of  iodine  applied  to  the  giun  margins  while  the  extraction  was  painless. 
These  peculiarities  have  not  been  explained.^ 

1  Theodor  Blum  has  an  excellent  article  in  Item?  of  Interest,  1908,  p.  181;   also 
Dental  Cosmos,  April,  1919. 


HYPERSENSITIVITY  OF  DENTIN  321 

Other  Considerations:  Rapid  beating  of  the  heart  is  variously 
said  to  be  due  to  the  suprarenin,  while  Silverman^  claims  it  occurs 
when  novocain  only  is  used.  The  writer  finds  it  as  well  as  any 
faintness,  which  is  rare,  to  be  rapidly  amenable  to  aromatic  spirits 
of  ammonia.  Camphorated  validol  is  also  recommended  by  Reith- 
miiller.  These  or  bromural  may  be  given  in  advance  to  nervous 
patients.  Anesthetics  should  not  be  injected  into  septic  areas, 
especially  abscesses,  as  toxins  or  bacteria  may  be  forced  into  the 
blood  or  adjacent  parts.  Some  claim  that  this  is  the  cause  of  any 
toxic  symptoms  which  may  later  be  produced,  but  the  author  had 
one  such  case  in  which  the  patient  left  the  office  apparently  normal 
but  had  to  be  helped  home  from  the  street  car,  and  there  was  given 
coffee  liberally.  The  injection  was  aseptically  made  into  healthy 
gum  tissue  on  both  sides  of  a  bicuspid  for  pulp  extraction.  In  another 
case,  in  which  one-third  grain  only  of  procain  was  used  for  a  mucous 
anesthesia  in  healthy  tissue  near  a  pyorrhea  pocket,  before  the  oper- 
ation could  be  done  the  patient  was  faint  and  vomited.  Silverman 
advises  a  slow  injection  occupying  a  full  minute.  As  erotic  s^Tiip- 
toms  are  said  to  occur  there  should  be  a  third  party  present  as  in 
general  anesthesia. 

Both  mucous  and  conductive  anesthesia  are  warrantable  procedures 
and  should  be  resorted  to  in  preference  to  long-continued  treat- 
ment of  cases  by  other  methods.  They  are  of  value  in  all  cases  of 
dentin,  pulp,  gingival,  pericemental  or  bone  disease  in  which  opera- 
tion would  be  unduly  painful.  Nevertheless  the  writer  does  not  use 
them  constantly  for  ordinary  cases  of  excavation,  pyorrhea  treat- 
ment, etc. 

In  case  a  needle  break  off  in  the  tissue  it  should  be  removed  as 
it  may  migrate  and  cause  trouble.  The  tissue  being  anesthetized 
if  the  injection  has  been  made,  or  specially  anesthetized  if  this  was 
not  done,  it  is  rational  to  make  a  cut  as  nearly  at  right  angles  to  the 
needle  as  may  be  and  deep  enough  to  feel  its  mesial  end.  The 
edges  of  the  cut  are  retracted  and  the  needle  grasped  and  removed 
with  suitable  forceps.     Berger^  describes  such  an  operation. 

In  apicoectomy  conductive  anesthesia  should  be  fortified  by  mucous 
anesthesia,  and  for  upper  anterior  teeth  Peck's  method  of  packing  the 
anterior  nares  with  cotton  and  a  20  per  cent,  solution  of  no\'ocain  is 
advocated  by  Prinz.- 

Mucous  OR  Infiltration  Anesthesia. — This  is  a  form  of  conduc- 
tive anesthesia  (as  related  to  this  subject)  in  which  injection  of  a  local 
anesthetic  is  made  beneath  the  periostemn  on  one  or  both  sides  of 

1  Items  of  Interest,  September,  1915,  p.  660. 

2  Dental  Ccsmos,  May,  1918,  p.  386. 
21 


322  DENTAL  CARIES 

the  alveolar  process  in  such  situation  as  to  infiltrate  the  apical 
tissue  and  the  branch  of  the  fifth  nerve  leading  from  the  pulp.  The 
short  needle  is  used,  its  orifice  facing  the  bone,  and  is  introduced  at 
a  point  as  nearly  over  the  apex  as  possible.  The  finger  is  placed 
over  it  and  a  slow  forcible  injection  made  with  endea\'or  to  massage 
the  solution  toward  the  apical  tissue.  The  results  are  best  when 
the  solution  does  not  escape  into  soft  tissues,  which  may  largely  be 
prevented  by  finger  pressure  higher  up.  No  good  effect  upon  dentin 
is  noted  unless  the  apical  tissue  is  infiltrated.  When  accomplished 
even  a  pulp  removal  can  be  done. 

For  extraction  the  aim  is  to  anesthetize  the  pericementum  and 
gum  tissue  and  the  injection  is  made  on  both  sides  of  the  alveolar 
process. 

Diploic  ok  Intraosseous  Anesthesia. — For  deep  anesthesia  about 
a  molar,  the  gum  may  be  anesthetized  and  a  cut  made  to  the  bone, 
a  small  sterile  drill  is  then  driven  through  to  the  cancellated  structure. 
A  further  injection  is  then  made  with  a  blunt  needle,  such  as  is  used 
in  high  pressure  work.  This  operation  has  been  modified  by  the  use 
of  a  needle  constructed  to  simply  indent  the  cortical  layer  of  bone,  so 
that  the  force  of  the  plunger  may  cause  the  direct  infiltration  of  the 
apical  tissue.  This  uses  the  principle  of  high  pressure  anesthesia 
as  applied  to  dentin. 

While  the  operation  of  diploic  anesthesia  seems  heroic,  there  is 
no  good  reason  for  so  regarding  either  this  or  the  operation  of  conduc- 
tive anesthesia  in  general  as  more  dangerous  than  ordinary  mucous 
injection.  The  rule  of  safety  lies  in  knowledge  of  anatomy,  safe 
dosage,  and  sterility — in  short,  in  correct  technique. 

The  introduction  of  a  5  or  10  per  cent,  solution  of  cocain  upon 
cotton  into  the  nostril,  upon  the  side  of  operation,  is  endorsed  by 
Peck,  of  Chicago,  as  a  means  of  anesthetizing  the  nerve  trunk 
leading  from  the  upper  incisors.  Escat,  of  Toulouse,  France,  has 
observed  that  a  0.1  per  cent,  solution  on  cotton  about  the  size  of  an 
almond,  placed  in  the  nostril  in  close  proximity  to  the  anterior  edge 
of  the  inferior  turbinate,  will  in  twenty  minutes  anesthetize  the 
anterior  superior  dental  branch  of  the  fifth  nerve,  which  lies  in  close 
proximity  to  the  nasal  mucous  membrane  at  this  point.  The  entire 
tissue  about  the  incisors  and  cuspids  of  the  side  is  anesthetized,  as 
is  sometimes  that  of  the  opposite  side  in  part. 

Reflex  Anesthesia. — Claims  are  made  by  Dr.  William  H. 
Fitzgerald,  M.D.,  that  pressure  with  a  metal  probe  tipped  with 
cotton  upon  certain  parts  of  the  mouth  and  fingers,  will  produce 
satisfactory  oral  anesthesia  and  even  of  more  distant  parts.     Cura- 


HYPERSENSITIVITY  OF  DENTIN  323 

tive  effects  in  certain  body  diseases  by  proper  manipulation  are 
claimed.     The  method  has  not  obtained  any  vogue. ^ 

Local  Treatment. — The  local  treatment  of  h\^ersensitive  dentin 
may  be  considered  from  two  standpoints,  according  to  whether  a 
concavity  containing  it  requires  excavation,  or  whether  the  hyper- 
sensitive spots  are  not  to  be  excavated  after  treatment. 

Treatment  in  Cavities  of  Decay. — ^The  remedies  employed  in 
the  endeavor  to  reduce  or  abolish  hypersensitivity  in  a  cavity  of 
decay  at  the  time  of  operation  are  quite  numerous;  few  are,  however, 
always  effective.    They  may  be  classed  under  two  headings : 

1 .  Those  which  temporarily  benumb  or  anesthetize  the  fibrillge  and 
prevent  the  transmission  of  sensation. 

2.  Those  which  chemically  destroy  the  fibrillee  for  a  distance,  thus 
preventing  transmission  of  sensation. 

Remedies  which  Benumb  the  Fibrill^. — Chief  among  these 
for  its  universality  of  application  is  dryness.  Dentin,  which  protests 
against  even  the  touch  of  an  instrument  while  wet,  has  its  sensitivity 
so  lessened  after  the  application  of  a  rubber  dam  and  drying,  that  it 
may  be  cut  freely,  in  many  cases  without  the  aid  of  medicinal  agents. 
So  well  is  this  recognized  that  isolation  and  drying  of  teeth  are 
regarded  as  a  necessary  preliminary  to  cavity  preparation.  The 
degree  of  insensitivity  induced  is  in  proportion  to  the  dryness.  The 
drying  temporarily  deprives  the  dentinal  protoplasm  of  a  portion  of 
its  water,  and  inhibits  the  transmission  of  sensation  by  reducing 
functional  activity. 

A  continuous  but  gentle  blast  of  air,  passed  from  a  compressed-air 
apparatus  or  double  bulb  through  a  heated  metal  bulb  and  nozzle, 
or  through  an  electrically  heated  coil,  should  be  employed  until  the 
dentin  is  desiccated.  This  is  evidenced  by  its  extreme  whiteness. 
Other  forms  of  hot-air  syringes  may  be  substituted  with  less  satis- 
faction and  greater  fatigue  to  the  operator.  The  double  bulb  may 
be  operated  by  the  patient. 

The  application  of  absolute  alcohol  assists  the  drying  because  of 
its  affinity  for  water.  The  addition  of  a  little  menthol  to  the  alcohol 
assists  by  anesthetic  action.  The  pain  from  the  warm  air  may  at 
first  be  quite  severe,  but  even  in  greatly  hypersensitive  cases  the 
nozzle  of  the  syringe  may  soon  be  approximated  to  the  cavity,  though 
in  some  cases  it  may  be  necessary  to  make  an  application  of  a  mixture 
of  equal  parts  of  carbolic  acid  and  oil  of  cloves,  or  of  gum  camphor 
and   carbolic   acid    (phenol   camphor),   both   of   which   have   some 

1  Items  of  Interest,  March,  1915. 


324  DENTAL  CARIES 

anesthetic  effect.  Menthol  may  be  added  to  either.  When  desirable, 
their  effect  may  be  hastened  by  pressure  with  unvulcanized  rubber. 

An  instrument  known  as  the  "dehydrator"  causes  absolute  alcohol 
placed  in  a  special  chamber  between  the  bulb  of  the  hot-air  syringe 
and  the  nozzle  to  be  vaporized  upon  the  hypersensitive  dentin. 
The  drying  effect  is  thereby  augmented  and  the  dentin  satisfactorily 
obtunded.  Natm-al  dryness  obtained  by  applying  rubber  dam,  mod- 
erate drying  with  warm  air  and  allowing  the  patient  to  wait  approxi- 
mately an  hour  has  been  very  effective  in  extreme  cases.^ 

Some  degree  of  dryness  is,  as  a  rule,  a  necessary  preliminary  to 
success  with  other  applications. 

Following  dryness,  the  excavation  should  be  done  with  sharp 
instruments  and  burs.  The  latter  should  only  be  lightly  touched  to 
the  dentin  and  be  revolved  at  high  speed.  Letting  the  bur  occa- 
sionally run  free  cools  it.  The  heat  of  friction  is  considerable  and 
highly  irritating. 

The  combination  of  potassium  carbonate  with  glycerin  makes  a 
water-extracting  combination  having  but  little  coagulating  power. 
For  this  reason  it  may  be  used  in  the  deeper  cavities,  but  not  in  cases 
of  almost  exposed  pulp,  as  in  such  cases  its  application  is  painful. 

I^ — Potassium  carbonate gr.  xv 

Glycerin f3j 

Mix  in  a  mortar. 

To  be  applied  on  a  pellet  of  cotton.    (Flagg.) 

It  may  be  used  with  effect  even  upon  slightly  moist  dentin. 

Not  being  escharotic  to  the  gum,  this  remedy  is  exceedingly  useful 
about  the  sensitive  but  undecayed  necks  of  teeth,  and  may  be  freely 
applied  after  moderate  drying  of  the  parts. 

If  necessary,  the  patient  may  be  given  the  prescription  and  directed 
to  apply  by  means  of  a  clean  tooth-pick,  which  should  not  be  used 
a  second  time,  as  the  mixture  may  be  infected  and  spoiled. 

The  part  is  dried  with  a  bit  of  clean  cloth  and  the  material  applied. 
The  mouth  is  kept  open  until  the  pain  ceases. 

Its  pain  simulates  that  of  zinc  chlorid,  but  is  less  severe  in  its 
character. 

A  mixture  of  tannin  and  glycerin  has  a  similar  effect. 

IJ — Tannin 3J  or  3ij 

Glycerin fgj 

Mix  in  a  warm  mortar. 

Zinc  chlorid  by  its  affinity  for  water  also  acts  in  this  manner,  but 
being  also  a  caustic  it  is  described  with  the  next  class. 

1  Guilford,  lecture. 


HYPERSENSITIVITY  OF  DENTIN  325 

Hot  water  supplied  by  a  tube  leading  from  a  coil  heated  by 
electricity  and  attached  to  the  water  suppl}^  pipe  of  the  fountain 
cuspidor  has  been  recommended  by  A.  F.  Merriman,  Jr.,  for  the 
obtunding  of  hypersensitive  dentin  in  cases  in  which  dryness  is  not 
readily  obtainable,  nor  immediately  or  subsequently  desirable. 

It  is  claimed  that  satisfactory  analgesia  is  obtained,  and  that  the 
mucous  membrane  of  the  mouth  is  not  unduly  uncomfortable,  even 
when  the  heat  is  objectionable  to  the  finger  of  the  operator.  The 
advantages  of  the  method  for  excavation  and  grinding  are  obvious 
and  most  useful,  particularly  for  trimming  live  teeth.  A  spray  of 
blood-warm  water  from  an  atomizer  operated  by  compressed  air  may 
be  used  with  the  bar  or  stone  with  satisfaction. 

Buckley^  has  recommended : 

^. — Mentholis gr.  xx 

ChJoroformi ' f.^ij 

Etheris qs.  ad.   fSjM. 

Sig. — Place  a  little  on  cotton  in  the  cavity  after  the  rubber  dam  is  adjusted  and 
.^aporate  to  dryness. 

Refrigeration  by  a  spray  of  ether  or  ethyl  or  methyl  chlorid  reduces 
the  temperature  of  the  fibrils  and  pulp,  benumbing  them.  The 
rubber  dam  should  be  applied  to  isolate  the  teeth  operated  upon. 
Ether  and  Rhigolene  are  applied  by  means  of  a  double-bulbed 
atomizer,  or  one  operated  by  compressed  air;  the  chlorids  are 
contained  in  glass  tubes  conveniently  capped  which  conserve  the 
preparation.  The  cap  being  raised,  the  heat  of  the  hand  causes 
vaporization  of  the  agent  within  the  tube,  which  forces  the  liquid 
out  of  the  orifice  of  the  tube  in  a  fine  but  forcible  stream.  A  spraying 
nozzle  is  also  obtainable.  The  cavity  should  at  first  contain  a  pellet 
of  cotton,  in  order  that  the  dentin  may  be  gradually  obtunded  and 
painful  response  on  the  part  of  the  pulp  avoided.  The  method  may 
be  painful  in  application,  but  often  satisfactory.  Ether  odorizes  the 
operating  room,  and  a  flame  must  be  avoided. 

"Vapocain"  and  "  potassocain,"  proprietary  agents  which  consist 
of  a  15  per  cent,  solution  of  cocain  in  ether,  are  applied  to  hyper- 
sensitive dentin  upon  the  theory  that  the  ether  enters  the  tubules, 
carrying  the  cocain  into  contact  with  the  fibrils;  the  ether  evapo- 
rates, leaving  the  cocain  in  aqueous  solution  to  benumb  them.  This 
requires  several  minutes.  They  are  useful  in  the  deeper  cavities. 
Jack  recommended  that  the  cavity  acidity  be  neutralized  before  their 
application." 

1  Dental  Cosmos,  August,  1907,  p.  328. 

2  American  Text-book  of  Operative  Dentistry. 


326 


DENTAL  CARIES 


A  10  to  25  per  cent,  solution  of  cocain  hydrochloric!,  or  novocain 
in  water  may  be  forced  into  the  tubules  by  applying  it  on  a  pellet  of 
amadou,  placing  over  this  soft  vulcanite  rubber,  and  producing 
pressure  with  a  burnisher  for  from  three  to  six  minutes.  The  pressure 
should  be  gradually  applied.  A  gratifying  degree  of  dentinal  anes- 
thesia may  often  be  obtained. 

Adrenalin  chlorid  solution,  1  to  1000,  plus  chloreton^  or  cocain, 
has  been  used  in  this  manner  with  some  effect.  A  few  crystals  of 
the  cocain  or  novocain  may  be  picked  up  on  a  pellet  of  cotton  moist- 
ened with  warm  water  and  pressed  upon  the  cavity  surface. 

Fig.  320 


Ethyl  chlorid  spray  tube. 

Buckley^  recommends  spreading  cocain  alkaloid  made  into  a 
creamy  paste  with  liquid  petroleum  or  oleate  of  cocain  over  the 
surface  of  cavities  in  children's  teeth  and  sealing  for  a  day  or  two. 

Miller*  has  shown  that  by  taking  a  modelling  composition  impres- 
sion of  the  cavity,  then  applying  a  few  threads  of  cotton  saturated 
with  cocain  to  the  floor  of  the  cavity,  then  placing  a  thickness  of 
rubber  dam  over  the  entire  cavity  surface,  replacing  the  modelling 
composition,  and  producing  pressure,  anesthesia  can  be  produced 
when  there  is  not  a  greasy  condition  of  the  cavity,  nor  thick  layers  of 
decalcified  dentin  nor  much  secondary  dentin  present. 

Soderberg^  has  shown  that  painless  excavation  of  cavities  other- 
wise uncontrollable  may  be  effected  by  the  use  of  nervocidin,  an 
alkaloid  obtained  by  Dr.  D.  Dalma  from  the  East  Indian  plant 
gasu-hasu.  Twenty-four  hours  are  required  for  complete  dentinal 
anesthesia  without  pulp  anesthesia  unless  a  second  application  be 
made. 

The  primary  effect  of  nervocidin  being  irritating,  Soderberg  recom- 
mends the  additional  use  of  cocain,  both  being  mixed  with  zinc 
sulphate  cement. 


1  Parke,  Davis  &  Co. 
3  Dental  Review,  1906, 


2  Johnson's  Operative  Dentistry 
4  Dental  Cosmos,  August,  1903. 


HYPERSENSITIVITY  OF  DENTIN  327 

I^ — Gum  arabic 3j 

Zinc  sulphate §S3 

Water fSJ— M. 

Dissolve  the  zinc  sulphate  in  the  water,  add  the  gum  arabic,  stir;  let  stand  for 
twenty-four  hours  and  strain. 

I^ — Of  above  solution fgij 

Nervocidin gr.  x 

Cocain  hydrochlorid gr.  x — M. 

To  a  portion  of  the  latter  solution  add  uncalcined  zinc  oxid  to 
make  a  cement,  which  is  placed  in  the  dried  cavity.  Uncalcined  zinc 
oxid  added  to  the  first  formula  makes  zinc  sulphate  cement.  After 
excavation   the   acidity   of  the   nervocidin   should   be   neutralized. 

Cataphoresis  (Greek  kata,  down,  and  phoreo,  I  bear  or  bring)  is, 
in  technical  parlance,  the  transference  of  substances  from  the  anodal 
or  positive  pole  of  a  battery  toward  the  cathodal  or  negative  pole. 
They  are  thus  carried  into  the  tissues. 

Cataphoresis  is  to  be  distinguished  from  electrolysis,  by  which 
substances  are  decomposed  and  their  elements  carried  from  positive 
to  negative  or  from  negative  to  positive  poles,  according  to  their 
polarity.  In  cataphoresis  a  substance  is  carried  unchanged  from  the 
positive  toward  the  negative  pole,  after  the  manner  of  granules  in 
protoplasm  acted  upon  by  the  same  force. 

The  conduction  of  cocain  from  +  to  —  poles,  that  is,  in  one 
direction  only,  in  this  manner,  has  been  questioned  by  Sturridge, 
who  is  of  the  opinion  that  the  cocain  dissolved  in  water  is  split 
into  ions  (in  this  case  minute  fragmented  particles  of  molecules 
with  an  equal  number  of  +  and  —  ions  each  conducting  electricity 
and  travelling  in  opposite  directions  to  their  respective  (opposite) 
poles).  In  this  case  only  the  positively  electrically  charged  ions 
will  travel  toward  the  negative  (the  hand)  into  the  pulp.  There  is 
a  further  possible  view  of  which  there  is  no  evidence  of  which  the 
WTiter  is  aware,  that  the  cocain  is  electroh'zed,  the  resulting  ions 
which  have  anesthetizing  power  being  conveyed  into  the  fibrils  or  pulp 
tissue. 

As  applied  to  dentistry,  a  primary  current  from  a  battery  capable 
of  delivering  from  30  to  40  volts  has  the  positive  pole  or  conductor 
connected  with  a  resistance  or  cm-rent  controller,  capable  of  being 
so  mam'pulated  as  to  gradually  reduce  the  resistance  to  the  current  a 
fraction  of  a  volt  at  a  time.  This  is  called  a  "fractional  volt  selector." 
This  is  usually  a  "broken  ring"  of  graphite,  to  one  end  of  which  the 
positive  cm-rent  is  admitted  by  means  of  the  conducting  cord  and 
travelling  indicator;  at  the  other  end  the  current  passes  out  by  a 
similar  cord,  which  in  turn  is  attached  to  a  milliamperemeter,  or 
instrument  recording  the  quantity  of  current  passing  through  the 


328  DENTAL  CARIES 

circuit.  From  this  a  cord  leads  to  the  positive  electrode  applied  to 
the  tooth  cavity.  To  the  face,  neck,  or  wrist  of  the  patient  a  moist 
electrode  (negative)  is  applied,  which  by  its  conducting  cord  leads 
the  current  back  to  the  negative  or  zinc  pole  of  the  battery.  The 
current  passes  in  turn  from  the  battery  through  the  resistance, 
milliamperemeter,  dentinal  fibrils,  pulp,  arm,  hand,  to  the  battery. 

The  milliamperemeter  is  a  convenient  but  not  an  essential  feature 
of  the  apparatus,  and  as  a  volt-selector,  a  rod  of  graphite  or  a  glass 
tube  with  water  resistance  may  be  used.  Fig.  321 .  shows  the  more 
elegant  apparatus  arranged  almost  as  described.  An  ionizing  appa- 
ratus is  constructed  upon  exactly  the  same  principles  and  they  are 
therefore  interchangeable. 

In  the  use  of  the  cataphoric  apparatus,  the  tooth  is  securely  in- 
sulated by  well-ligated  rubber  dam  and  cotton  saturated  with  a 
solution  of  cocain  hydrochlorid  or  citrate,  of  a  strength  of  from  10 
per  cent,  to  a  saturated  solution  is  placed  in  the  cavity.  The  platinum 
anode  is  wrapped  with  cotton,  dipped  in  the  solution,  and  inserted 
into  contact  with  the  cotton  in  the  cavity.  The  controller  is  now  so 
manipulated  as  to  gradually  cut  out  its  resistance  to  the  current. 
When  pain  is  felt  the  controller  is  turned  back  slightly  until  it  passes 
and  then  again  advanced.  The  high  resistance  of  the  dentin  is  gradu- 
ally overcome. 

The  cocain  solution  should  be  renewed  as  dryness  occurs,  as  dryness 
increases  the  resistance.  The  cocain  is  carried  along  the  fibrils  to 
the  pulp  by  the  electric  current,  and  dentinal,  followed  by  pulpal 
anesthesia  results.  . 

From  eight  to  fifteen  minutes,  or  sometimes  longer,  are  required 
for  dentinal  anesthesia,  which  loss  of  time  is  largely  regained  in  the 
facility  of  operation.^ 

Price^  has  shown  that  pulp  anesthesia  is  gained  more  readily  by 
concentrating  the  action  of  the  cocain  upon  the  pulpal  wall  by  means 
of  a  small  electrode.  If  general  dentinal  anesthesia  is  required  he 
prefers  this  method,  as  the  pain  receptivity  of  the  pulp  is  abolished. 
A  broader  application  anesthetizes  the  dentin. 

Woodward^  has  shown  that  in  the  latter  case  the  dentin  in  a  cavity 
upon  the  opposite  side  of  a  tooth  being  operated  upon,  may  remain 
sensitive.  This  indicates  that  the  pulp  bulb  has  not  been  entirely 
anesthetized  and  is  about  the  best  point  to  which  to  advance  the 
anesthesia. 

The  pulp  is  not  injuriously  affected  in  ordinary  applications,  unless 

'Jack:  American  Text-book  of  Operative  Dentistry.    ^  Dental  Summary,  April.  1903. 
5  International  Dental  Journal,  November,  1902. 


HYPERSENSITIVITY  OF  DENTIN 


329 


saturated  by  long  application.    A  reaction  resulting  in  hyperemia  may 
take  place.    To  obviate  this,  the  pulp  should  not  be  oversaturated,  the 


Fig.  321 


S.  S.  White  cataphoric  outfit.  The  connections  with  the  patient  are  not  in  the 
illustration.  The  small  electrode  is  the  one  applied  to  the  tooth;  the  larger  is  for  the 
hand.    The  direction  of  current  will  depend  upon  the  connections  at  the  battery. 


330  DENTAL  CARIES 

fibrils  should  be  treated  with  carbolic  acid,  and  in  deep  cavities  a 
thermal  non-conductor  should  be  used  before  filling. 

In  case  absolute  insensitivity  is  produced,  the  anatomy  of  the  pulp 
must  carefully  be  considered,  so  that  it  be  not  exposed  during  the 
excavation  of  the  cavity.  This  can  be  determined  by  instrumental 
examination. 

The  pulp  may  have  cocain  or  novocain  forced  into  it  by  means  of 
a  powerful  compound-pressure  syringe.  The  Meyers  syringe  is  one 
of  the  best.  It  is  filled  with  a  2  per  cent,  solution  of  cocain  or  novocain 
in  Ringer  or  salt  solution.  A  convenient  drill  pit  is  made  with  a 
No.  I  bur;  this  may  at  first  be  but  part  w^ay  through  the  enamel  if 
necessary,  usually  it  is  made  in  the  dentin;  the  tapered  nozzle  of  the 
filled  syringe  freed  of  air  is  forced  into  the  opening  and  continuous  or 
intermittent  pressure  produced  without  releasing  the  point  for  several 
minutes.    It  is  well  to  allow  the  air  to  escape  from  the  pit  by  holding 

Fig.  322 


The  Meyers  compound  syringe  for  forcing  cocain  solutions  through  the  dentinal 

tubules. 


loosely  for  a  moment.  If  the  pit  is  made  in  the  enamel  only  such  time 
as  required  to  deepen  it  painlessly  need  be  given  (twenty  to  sixty 
seconds).  If  preferred  the  needle  may  have  a  flat  end  and  the  drill 
pit  be  made  with  a  cone-shaped  bur.  The  object  is  a  tight-fitting 
joint  as  leakage  causes  failure  of  force.  An  average  of  about  three 
minutes  will  be  required  for  sufficient  infiltration  of  the  pulp.  There 
are  occasional  failures  in  this  method.  No  general  cavity  anesthesia 
will  result  until  the  solution  has  infiltrated  the  area  of  pulp  underlying 
the  fibrillar  connections  with  the  pulp.  The  forcing  of  cocain  into  so 
delicate  a  tissue  should  stop  at  that  point,  unless  pulp  removal  is  in- 
tended, as  more  may  produce  expansive  pressure,  and  may  cause  a  later 
pulp  reaction,  as  cocain  is,  to  a  degree,  a  protoplasmic  poison.  It  should 
be  so  injected  into  only  sound  dentin  or  enamel.  If  the  cervix  of  a 
cavity  is  used  as  the  point  of  injection,  the  pit  should  be  made  deeper 
than  the  syringe  nozzle  penetrates,  as  in  this  way  the  lateral  tubules 
can  carry  the  cocain,  otherwise  they  may  be  occluded  by  the  syringe 


HYPERSENSITIVITY  OF  DENTIN  331 

point.  Ingalls^  has  devised  a  syringe  in  which  the  force  is  appHed  by 
compressed  air.  Secondary  dentin  is  difficult  of  penetration,  and 
gradual  approaches  must  be  made.  The  method  is  useful  in  pulp 
extirpation  rather  than  in  hypersensitivity,  but  has  occasional  use, 
especially  in  cervical  ca\'ities.  J/ 

Remedies  which  Chemically  Destroy  the  Fibrils  for  a 
Distance,  Preventing  Transmission  of  Sensation. — Agents 
which  chemically  destroy  the  dentinal  protoplasm  form  the  most 
extensive  group  of  dentinal  obtundents.  They  include  salts  of 
metals,  such  as  zinc  chlorid  and  silver  nitrate;  carbolic  acid  and  its 
derivatives,  and  like  bodies;  the  cresols,  etc.;  mineral  acids,  notably 
sulphuric,  chromic,  and  nitric;  organic  acids — trichloracetic  and  lactic 
acids— (full  strength) ;  alkalies — sodium  and  potassium  hydrates  and 
carbonates. 


Zinc  chlorid,  silver  nitrate,  and  carbolic  acid  all  cause  coagulation 
of  the  fibrils  of  the  dentin.  The  mineral  and  organic  acids^  cEemic- 
ally  decompose  both  protoplasm  and  the  calcified  tissues.  The 
concentrated  alkalies  chemically  destroy  protoplasm  and  bring 
about  its  quick  dissolution.  Like  all  active  chemical  substances,  the 
extent  of  their  action  depends  upon  the  freedom  with  which  they 
are  applied. 

The  application  of  any  of  these  agents,  as  a  rule,  causes  pain,  the 
degree  of  suffering  being  usually  in  proportion  to  the  depth  of  the 
cavity.  For  this  reason  the  more  powerful  agents,  like  zinc  chlorid 
and  nitric  acid,  are  to  be  confined  to  cavities  of  moderate  depth, 
while  carbolic  acid,  especially  in  combination  with  the  oil  of  cloves, 
may  be  used  in  the  deeper  ones. 

Fused  zinc  chlorid  is  used  in  its  deliquesced  form,  and  is  most 
active  when  some  of  the  salt  is  still  undissolved  in  the  bottle.  Its 
pain  in  suitable  cavities  is  a  full,  bearable  one,  gradually  increasing, 
sometimes  in  waves,  until  a  crisis  is  reached,  when  the  pain  gradually 
ceases.  It  has  a  double  action,  not  only  coagulating  protoplasm, 
but  combining  with  its  water,  owing  to  its  affinity  for  the  latter. 
On  account  of  this  property  its  action  may  be  limited  by  warm  water. 

An  undue  action  of  the  zinc  chlorid  is  indicated  by  a  throbbing 
pain;  this  indicates  that  the  pulp  has  been  irritated.  When,  as  occa- 
sionally occurs,  no  pain  is  produced,  no  obtundent  effect  is  obtained. 
If  this  occur  regularly  the  drug  is  oversaturated  with  water. 

Bogue  has  suggested  that  cocain  crystals  be  incorporated  with 
the  chlorid  of  zinc  as  a  means  of  alleviating  the  pain  incident  to  the 
application. 

^  Items  of  Interest.  January    1916. 


332  DENTAL  CARIES 

Miller,  following  HofPheinz,  advocated  the  use  of  equal  parts  of 
zinc  chlorid  and  chloroform. 

Buckley  modified  this  by  using  the  following: 

T^ — Zinc  chlorid .      .      .  gr.  xx 

.\lcohol f5iv 

Chloroform fSj — M. 

Apply  on  cotton  gently  evaporate  to  dryness. 

Certain  moderately  deep  cavities  may  be  filled  with  oxy chlorid  of 
zinc  cement,  the  free  zinc  chlorid  acting  as  an  obtundent.  This 
requires  a  prolonged  action,  and  is  only  resorted  to  in  cases  which 
do  not  admit  of  immediate  w^ork,  or  in  which  procrastination  is 
desirable. 

A  formula  of  wide  renown  is  known  as  Robinson's  remedy ;  this 
may  be  made  in  one  of  two  ways: 

I^ — Potassium  hydrate 

(or  Sodium  hydrate), 

Carbolic  acid p.  aeq. — M. 

Reduce  the  gelatinous  mass  formed  with  alcohol. 

Or, 

I^ — Sodium  hydrate  (deliquesced), 

Calvert's  crystal  carbolic  acid      ....     p.  aeq. — M.    (Huey.) 
The  liquid  formed  is  spoiled  when  it  effloresces  upon  the  sides  of  the  bottle  neck. 

The  painfully  caustic  action  of  the  sodium  or  potassium  hydrate 
is  modified  by  the  carbolic  acid. 

The  application  of  Robinson's  remedy  is  useful  in  the  simpler 
cavities  and  about  the  undecayed  but  hypersensitive  necks  of  teeth 
and  on  occlusal  surfaces.     It  is  escharotic  to  the  gum. 

If  this  remedy  or  zinc  chlorid  be  required  about  the  periphery  of 
deep  cavities  the  plan  suggested  by  Jack,  of  varnishing  the  cavity 
floor  with  chloro-percha  as  an  impenetrable  protective  is  valuable. 

A  method  similar  to  the  use  of  Robinson's  remedy  consists  in  apply- 
ing carbolic  acid  to  a  cavity  and  then  without  removing  it,  placing  a 
few  granules  of  sodium  dioxid.^  Sodium  dioxid  alone  in  a  slightly 
moist  cavity,  liberates  nascent  sodium  hydrate  (also  H2O2),  which 
will  destroy  the  gum  protoplasm,  and  is  somewhat  effective  in  hyper- 
sensitive dentin. 

Carbolic  acid  in  concentrated  form  may  be  applied  to  any  cavity. 
Jenkins,  of  Dresden,  has  recommended  that  it  be  used  hot;  it  is 
particularly  useful  for  cavities  containing  masses  of  softened  dentin. 
A  variation  consists  in  the  application  to  the  cavity,  upon  a  pellet 
of  cotton,  and  heating  it  with  a  hot  burnisher. 

Sodium  bicarbonate  is  at  times  an  efficacious  remedy,  and  may  be 

1  H.  J.  Moore:  Dental  Review,  1906. 


HYPERSENSITIVITY  OF  DENTIN  333 

freely  applied  to  the  moist  cavity.     A  20  per  cent,  solution  of  am- 
monium carbonate,  applied  for  five  minutes  or  longer,  is  useful.^ 

The  nitrate  of  silver  powerfully  coagulates  fibrillar  protoplasm, 
forming  the  albuminate  of  silver,  which  turns  black  upon  exposure 
to  the  light.  It  is  useful  in  posterior  teeth  well  out  of  view,  and  to 
which  the  rubber  dam  cannot  well  be  applied.  It  is  also  useful 
about  undecayed  hypersensitive  necks  of  molar  teeth.  It  penetrates 
the  dentin  for  a  short  distance.  For  this  reason  its  use  is  ordin- 
arily confined  to  posterior  teeth,  though  in  some  obstinate  cases  of 
hypersensitive  necks  of  lower  incisors  and  cuspids  it  may  be  used. 
To  prevent  the  production  of  hypersensitivity  in  teeth  ground  for 
bridge-work,  it  should  be  apphed  over  the  entire  cro^^^^.  If  amalgam 
be  not  present  a  bit  may  be  rubbed  o\'er  the  silver  nitrate  to  blacken 
the  surface.  Ready-made  aluminum  crowns  set  with  temporary 
stopping  may  also  be  used  for  this  piu-pose.  It  may  be  used  in 
saturated  aqueous  solution  upon  the  dried  dentin,  or  the  crystal 
rubbed  upon  the  slightly  moistened  dentin.  The  crystal  or  fused 
silver  nitrate  rubbed  upon  abraded  and  sensitive  occlusal  surfaces 
often  affords  much  comfort. 

Fig.  323 


Dentin  treated  with  silver  nitrate  at  a  only;  the  entire  surface  subjected  to  acid 
action  shows  penetration  at  b.    (Miller.y 

Craven's  method  consists  of  taking  up  a  few  crystals  upon  a  hot 
platinum  wire,  and  then  fusing  them  into  a  button  upon  its  rough- 
ened end.    This  is  then  rubbed  upon  the  dentin. 

Miller  has  shown  that  the  silver  deposit  lessens  the  penetration  of 
acid  decalcification  (Fig.  323). 

The  subsequent  use  of  sodium  chlorid  assists  in  partially  removing 
the  stains,  argentic  chlorid  being  formed. 

1  Thiesing:  Dental  Cosmos,  Nov.,  1903. 


334  DENTAL  CARIES 

Register  has  suggested  the  use  of  iodin  followed  by  ammonia  for 
this  purpose. 

Coming  into  contact  with  an  amalgam  filling,  or  a  bit  of  amalgam, 
an  intensely  black  deposit  is  instantly  produced,  which,  while  acid  at 
first,  is  useful  in  slowly  obtunding  dentin  in  cavities  out  of  view. 
Curiously  enough,  not  all  amalgams  do  this.  It  also  occurs  where 
amalgam  fillings  or  alloyed  gold  has  been  in  contact  with  dentin  so 
there  it  is  probably  a  reaction  between  silver  nitrate  and  copper  or 
silver  and  not  necessarily  dependent  upon  mercury. 

For  severe  cases  not  yielding  to  local  treatment  at  the  time  desired, 
the  following  has  been  recommended.^  a   ,         ^    /l/"Vi.u4-W  ' 

I^— Trioxymethylene  -^-^'^^"^^  \   V\ 

Orthoform    .      .      .    ^.      .      .^.^ p.  seq.. 

Make  into  a  paste  with  carbolic   acid. 

Or, 

IJ — Menthol  crystals 5  parts. 

Phenol  crystals 4  parts. 

Reduce  to  a  syrupy  liquid  to  be  used  in  place  of  the  carbolic  acid  in  the  above 

formula. 

This  paste  is  applied  to  the  cavity  walls  over  even  decayed 
dentin,  covered  with  a  pellet  of  cotton,  and  sealed  in  with  temporary 
stopping  or  cement  for  twenty-four  hours  only.  Formaldehyd  gas 
is  liberated  in  the  nascent  state  and  desensitizes  the  fibrils  by  harden- 
ing and  fixing  them  as  in  histological  specimens.  The  orthoform 
acts  as  an  anesthetic  during  the  action  of  formaldehyd.  This  prin- 
ciple has  been  used  in  cavities  with  the  ordinary  37  per  cent, 
formaldehyd  solution,  applied  by  the  pressure  method,  and  is  useful 
about  the  hypersensitive  necks  of  teeth.  Buckley^  has  recently 
introduced  a  modification  in  a  paste  form  having  similar  action. 

I^ — Neothesin  (Lilly) s^o  grain. 

Trioxymethelene ^V  grain. 

Thymol 370  grain. 

Petroleum  base,  coloring  matter,  and  fibre. 

(The  figures  indicate  the  approximate  quantities  in  one  application.) 
S. — Apply  to  dry  dentin  and  cover  with  cement  for  twenty-four  to  forty- 
eight  hours. 

In  shallow  labial  cavities  it  is  to  be  applied  and  covered  with 
very  adhesive  cement. 

This  preparation  has  excited  argument  as  to  its  pulp-devitalizing 
power.  Prinz  claims  that  it  is  an  agent  penetrating  and  devitalizing 
the  pulp,  while  many  competent  observers  say  that  it  does  not  do 
so  even  when  intentionally  used  for  that  purpose. 

1  G.  Mahe,  M.D.,  Paris:  Dental  Cosmos,  1904. 
^  Items  of  Interest,  December,  1914, 


HYPERSENSITIVITY  OF  DENTIN  335 

In  shallow  cavities  and  upon  abraded  surfaces,  nitric  and  chromic 
acid  accurately  applied  in  small  quantity  upon  a  gold  probe  is 
useful.    Any  softened  dentin  must  later  be  removed  and  filled. 

For  very  obstinate  cases  of  cervical  or  occlusal  hypersensitivity, 
Flagg  recommended  the  use  of  the  electric  cautery,  the  spots  to 
be  seared.  A  very  hot  burnisher  may  occasionally  serve.  If  this 
or  silver  nitrate  will  not  serve  filling  cupped-out  places  must  be 
resorted  to. 

Aside  from  the  treatment  of  hypersensitive  dentin,  at  the  time  of 
operation,  analgesics  may  be  introduced  for  their  power  of  gradu- 
ally lessening  the  hyperirritability  of  fibrillar  protoplasm.  If  cotton 
wedges  are  introduced,  antiseptic  analgesics,  particularly  oil  of 
cloves  (or  eugenol),  equal  parts  of  oil  of  cloves  and  carbolic  acid, 
and  phenol  camphor,  or  Fletcher's  carbolized  resin,  may  be  used  on 
the  cotton  with  advantage.  Chloral  and  menthol,  equal  parts, 
made  by  rubbing  in  a  mortar,  etc.,  may  be  sealed  in  on  cotton  for 
a  few  days  (Buckley). 

A  partially  prepared  cavity  may  be  moistened  with  eucalyptol 
and  temporarily  filled  with  temporary  stopping  or  gutta-percha. 
This  affords  rest.  If  the  gutta-percha  leak^  the  cavity  will  be  more 
sensitive. 

A  temporary  filling  made  by  mixing  zinc  oxid  with  Fletcher's 
_car.bolized  resin  or  eugenol  to  a  stiff  paste  will  endure  for  some 
time,  and  reduce  hypersensitivity.  It  is  also  useful  as  an  antiseptic 
sedative  test  filling. 

^ — Carbolic  acid, 

Colophony aa      5j 

Chloroform  .      .      .      .      .      . fgss — -M. 

(Fletcher.) 

A  temporary  filling  of  zinc  oxid  and  eugenol  will  set  in  the  saliva 
and  answer  the  purpose,  a  crystal  of  thymol  may  be  addecL 

In  cavities  not  permitting  exact  excavation,  oxyphosphate  of 
copper  cement  left  for  a  considerable  time  will  often  reduce  exquisite 
__sensitivity. 

The  use  of  chalk  applied  nightly  in  a  superficial  cavity,  as  at  the 
cervix,  is  useful  for  this  purpose. 

In  cases  in  which  devitalization  is  intended,  arsenic  may  be  used 
as  an  obtundent  to  effect  a  deeper  placing  of  another  portion  as  a 
devitalizing  agent;  twenty-four  to  forty-eight  hours  are  required  for 
this  purpose.  If  left  long  enough  it  will  devitalize  the  pulp  even 
through  a  large  mass  of  dentin. 

There  is  no  safety  in  short  applications  as  a  means  of  obtunding 
dentinal  hypersensitivity.  The  pulp  may  die  even  after  seeming 
excavation  of  all  affected  dentin. 


336  DENTAL  CARIES 

Ninety  per  cent,  of  cavities  may  be  comfortably  excavated  with 
sharp  instruments  by  the  aid  of  dryness  and  carboHc  acid  or  simple 
obtundents.  A  small  percentage  require  the  use  of  strong  caustics, 
etc.,  while  in  a  still  smaller  number  some  of  the  extreme  measures 
are  necessary,  though  nitrous  oxide  and  blocking  are  admissible  in 
all  cases  if  the  careful  operator  prefers  as  most  do  not. 

During  seasons  in  which  acid  fruits  are  consumed,  much  hyper- 
sensitivity may  be  induced.  This  should  always  lead  to  examination 
for  cavities  of  decay,  but  such  may  not  exist  or  may  be  properly  filled. 

For  hypersensitivity  about  undecayed  necks  of  teeth,  the  mouth 
should  be  kept  in  an  alkaline  condition  by  means  of  dilute  phenol 
sodique  or  sodium  bicarbonate,  or,  better,  by  the  use  of  more  lasting 
mild  alkalies,  such  as  chalk,  rubbed  into  the  necks  and  interspaces, 
or  milk  of  magnesia  (the  mouth  rinsed  with  a  small  quantity  and 
the  excess  expectorated  the  residuum  left),  or  a  combination  of  the 
two  may  be  used.  The  manufacturers  of  milk  of  magnesia  recom- 
mend a  series  of  oil  mixtures;  6  drops  of  any  mixture  to  be  shaken 
up  with  the  contents  of  the  original  bottle  as  a  flavor  to  remove 
the  naturally  raw  taste  of  the  preparation,  which  is  disagreeable  to 
some  persons.^    The  following  are  two  of  the  simplest : 

I^ — Oil  of  bitter  almond 1  part. 

Oil  of  anise ■  .      .     3  parts. 

Or, 

I^ — Oil  of  cinnamon 3  parts. 

Oil  of  wintergreen 4  parts. 

The  use  of  potassium  carbonate  in  glycerin  is  indicated  and  may 
be  given  to  the  patient  for  free  use.  The  patient  is  directed  to 
apply  chalk  thereafter.     (See  page  324.) 

For  hypersensitive  incisal  edges  or  occlusal  surfaces,  Robinson's 
remedy  may  be  thus  dispensed  with  a  caution  as  to  its  caustic  nature. 

At  times  zinc  chlorid,  Robinson's  remedy,  and  silver  nitrate  or  the 
actual  or  electric  cautery  must  be  used  by  the  operator. 

In  a  number  of  the  localized  cases  fillings  may  be  subsequently 
required  unless  rigid  prophylaxis  be  practised.  Prophylaxis  may 
remove  the  superficial  desensitized  layer,  and  the  application  require 
renewal.  I  have  been  informed  that  a  case  of  general  hypersensiti- 
vity was  cured  by  the  lemon  juice  treatment  given  for  systemic  con- 
dition. The  idea  is  worthy  of  attention.  It  might  be  explained 
upon  the  principle  of  induced  alkalinity  of  salivary  secretion  as 
organic  acids  are  known  to  increase  the  alkalinity  of  the  urine. 

The  use  of  potassium  sulphocyanate  internally  in  case  of  great 
general  dental  hypersensitivity  has  had  good  results  claimed  for  it, 
especially  in  pregnant  women.     (See  p.  271.) 

1  Items  of  Interest.  1905,  p.  977. 


CHAPTER  XI. 

DENTAL  CARIES:  THERAPEUTICS  AND  PROPHYLAXIS. 

According  to  the  depth  of  invasion  and  variations  in  the  thera- 
peutics involved,  caries  may  be  divided  into  eight  stages,  as  follows: 

1.  Superficial  caries,  or  that  stage  in  which  the  enamel  has  been 
partially  decalcified,  but  the  dentin  not  affected  (Fig.  278). 

2.  Simple  caries,  in  which  the  dentin  has  been  affected  slightly, 
in  such  manner  as  ordinarily  to  compel  the  formation  of  a  cavity 
and  its  filling  (Fig.  284). 

3.  Deep-seated  caries,  in  which  the  complete  excavation  of  the 
cavity  renders  pulp  injury  a  possibility,  but  the  pulp  is  not  very 
dangerously^  approached  (Figs.  281  and  291). 

4.  Almost  exposed  pulp.  This  is  a  refinement  of  the  preceding 
stage,  in  which  pulp  exposure  becomes  imminent  dimng  excavation 
of  the  cavity  and  special  therapeutics  are  demanded  (Fig.  324). 

5.  Exposed  pulp,  in  which  the  actual  exposure  of  the  pulp  by 
decay  or  by  accident  or  intention  during  excavation  renders  its 
treatment  necessary,  or  in  which  disease  of  the  pulp  compels  canal 
treatment. 

6.  Perforation  by  caries,  in  which  after  pulp  death  secondary  caries 
of  dentin  and  cementum  has  caused  an  opening  into  the  pericemental 
tract  (an  extension  from  the  condition  in  Fig.  300).     (See  Fig.  325.) 

7.  Loss  of  crown  by  caries. 

8.  Loss  of  root  by  caries. 

Each  of  these  stages  of  caries  requires  special  consideration  and  a 
therapeutics  adapted  to  each. 

THERAPEUTICS    OF    SUPERFICIAL   CARIES. 

About  cavity  margins,  beneath  green  stain,  etc.,  along  bucco- 
cervical  margins,  and  at  points  of  approximal  contact  of  teeth  may 
frequently  be  seen  areas  of  enamel  decalcification,  the  enamel  not 
being  entirely  penetrated  (Fig.  278). 

It  is  possible  at  times  to  remove  the  decalcified  portion  by  means 
of  carborundum  strips,  files,  or  disks.  If  the  surface  be  highly 
polished  by  means  of  pumice  and  chalk,  and  subsequent  prophyl- 
axis be  employed,  the  practice  may  be  endorsed  for  the  better  grades 
22  (337) 


338  DENTAL  CARIES 

of  teeth,  and  particularly  in  the  anterior  part  of  the  mouth.  As  a 
rule,  however,  the  attempt  to  remove  supposed  superficial  enamel 
caries  demonstrates  the  fact  that  the  enamel  is  deeply  affected,  and 
in  all  probability  the  dentin  as  well.  The  attempt  to  remove  such 
caries  upon  proximal  surfaces  by  files  and  stones  results  in  tooth 
deformity,  the  exposure  of  dentin  to  the  fluids  of  the  mouth,  and  the 
destruction  of  the  contact  points,  except,  perhaps,  when  in  the 
anterior  teeth  a  lingual  approach  is  made.  It  is  sometimes  proper  to 
remove  the  slight  superficial  caries  found  about  a  cavity,  either  prior 
to  excavation  in  order  to  determine  the  real  cavity  boundary,  or 
after  excavation  if  such  removal  would  give  an  even  better  tooth 
form,  and  lessen  a  recurrence  of  decay,  or,  in  some  cases,  after  filling 
when  both  filling  and  margin  are  reduced  together  to  a  proper 
form  and  integrity  of  enamel.  Some  judgment  is  required  in  such 
a  matter,  and  no  enamel  should  be  so  treated  if  any  doubt  exist  as 
to  its  future  integrity,  but  the  cavity  should  rather  be  extended  to 
include  the  doubtful  area.     (See  Fig.  284  for  contra-indication.) 

It  may  be  considered  a  safe  rule  to  examine,  by  means  of  the  electric 
mouth  lamp,  any  cases  of  suspected  superficial  caries  in  order  to 
determine  the  depth  of  enamel  invasion. 

The  large  majority  of  such  cases,  especially  in  the  poorer  grades 
of  teeth,  will  be  found  to  be  of  the  class  called  here  simple  caries. 

Upon  the  labial  or  buccal  surfaces  of  anterior  teeth  a  superficial 
decalcification  may  be  found.  Whether  (1)  this  shall  be  removed 
and  the  surface  polished,  or  (2)  be  left  for  the  patient  to  care  for 
by  exact  prophylaxis,  or  (3)  be  excavated  and  filled,  depends  upon 
the  location,  the  depth  of  penetration,  and  the  progress  of  the 
enamel  decalcification.  The  writer  has  carried  forward  for  a  long 
time  numerous  white  crescentic  markings  by  prophylaxis  which 
removes  microbic  plaques  and  food  and  aborts  decalcification, 
though  not  removing  the  tissue  decalcified. 

In  posterior  teeth  staining  with  silver  nitrate  alone  or  by  touching 
later  with  amalgam  to  produce  a  rapid  deposit  of  silver,  grinding 
off  with  stones  and  then  touching  with  silver  nitrate,  or  filling  the 
actual  cavity  with  oxyphosphate  of  copper  and  staining  and  watch- 
ing the  remaining  decalcification,  have  all  given  good  results  when 
conjoined  with  improved  prophylaxis  by  the  patient.  Superficially 
decayed  cementum  may  be  removed  or  not  and  silver  nitrate  applied. 
This  applies  to  only  slight  depths  of  decalcification.  These  spots 
are  often  deeper  than  at  first  thought  and  they  should  be  somewhat 
forcibly  penetrated  with  the  explorer  to  determine  the  point;  if 
fairly  deep  and  in  locations  not  readily  cleansed  they  should  be  filled. 


THERAPEUTICS  OF  DEEP-SEATED  CARIES  339 


THERAPEUTICS    OF    SIMPLE    CARIES. 

The  cases  cited  above  as  requiring. excavation  and  all  detectable 
cavities  of  very  limited  depth  may  be  classed  as  cases  of  simple 
caries.  The  teeth  should  be  wedged  apart  if  this  be  needed  for  access, 
all  decalcified  enamel  and  dentin  removed,  the  cavity  properly 
extended  and  shaped,  and,  as  a  rule,  a  metal  filling  inserted.  All 
fissures  about  a  cavity  should  be  freely  opened  to  their  extremities, 
and  made  a  part  of  the  general  cavity. 

The  extension  upon  approximal  surfaces  should  include  all  super- 
ficial decay  that  cannot  be  so  disked  off  as  to  bring  the  filling  margin 
into  the  embrasures. 

The  treatment  of  simple  approximal  cavities  is  a  difficult  question. 
Undoubtedly  extension  enhances  the  longevity  of  the  fillings.  At 
times,  however,  the  cavities  may  be  kept  purely  approximal  and  by 
the  use  of  gutta-percha,  silicate  cement  or  combination  of  amalgam 
and  zinc  phosphate  cement  renewed  or  repaired  as  required,  the  case 
can  be  controlled  for  many  years.  This  may  be  advisable  in  anterior 
teeth  where  gold  may  be  objectionable  or  when  systemic  conditions 
or  uncontrollable  sensitivity  warrant  it.  In  the  main,  if  endurable, 
cavities  in  posterior  teeth  should  be  extended,  otherwise  the  renewal 
of  the  fillings  will  probably  in  time  be  necessary.  In  the  anterior 
teeth  esthetics  often  warrants  keeping  the  cavities  small.  The 
question  is  one  which  can  be  settled  after  consideration  of  all  the 
requirements.  Subsequent  prophylaxis  is  of  importance,  and  to  that 
end  all  fillings  should  be  made  as  smooth  and  perfect  as  possible. 

If  a  simple  cavity  prove  inordinately  sensitive,  the  more  powerful 
remedies  may  be  freely  used  to  reduce  the  hypersensitivity,  and  the 
cavity  should  be  treated  with  carbolic  acid  before  filling,  particularly 
when  gold  is  to  be  used  in  cervicolabial  cavities  of  incisors.  By  this 
means  the  subsequent  effect  of  thermal  changes  is  lessened, 

THERAPEUTICS    OF   DEEP-SEATED   CARIES. 

In  this  stage  of  caries  there  is  usually,  although  by  no  means  always, 
an  easily  discoverable  cavity  of  size  (Fig.  291).  After  the  removal 
of  ragged  and  overhanging  enamel  margins,  and  of  loose  debris  in 
the  cavity,  it  is  noted  that  the  response  to  thermal  impulse  is  painful 
and  prompt.  In  washing  such  cavities,  water  at  a  temperature  of 
about  100°  F.  should  always  be  used;  cold  or  very  hot  water  being 
only  employed  in  cavity  irrigation  to  test  the  promptitude  of  response 
upon  the  part  of  the  pulp.     It  is  better  to  do  this  habitually. 


340  DENTAL  CARIES 

In  treating  hypersensitivity  of  dentin  carbolic  acid  is  to  be  pre- 
ferred, the  mineral  acids  are  avoided,  and  if  strong  agents  like  zinc 
chlorid  or  Robinson's  remedy  are  used,  the  cavity  floor  is  to  be 
varnished  with  chloro-percha  or  "cavitine"  varnish,  which  are 
impermeable.  If  necessary  the  sedative  temporary  methods  may 
be  employed  or  the  various  anesthetic  methods  may  be  used,  pulp 
exposure  being  carefully  avoided.     (See  p.  314.) 

The  removal  of  all  the  softened  dentin,  which  should  be  done  in 
these  cases,  forms  a  cavity  of  such  magnitude  that  proximity  to  the 
pulp  is  evident.  The  softening  has  proceeded  for  a  distance  beneath 
the  enamel,  so  that  when  all  softened  dentin  is  cut  away  from  beneath 
it  the  latter  tissue  may  overhang  the  general  cavity  unsupported. 
These  overhanging  walls  are  cut  away  until  the  region  of  strong 
enamel  is  reached,  and  then  it  may  be  that  the  walls  still  overhang 
the  general  cavity.  It  is  usually  not  necessary  nor  advisable  to 
remove  this  portion  of  enamel. 

At  the  completion  of  excavation  the  pulpal  wall  of  the  cavity  will 
be  in  fair  proximity  to  the  pulp.  A  blast  of  cool  air  from  a  chip 
syringe  may  produce  an  immediate  response  upon  the  part  of  the 
pulp,  vigorous  in  proportion  to  the  thinness  of  its  dentinal  covering 
and  its  irritability. 

In  many  cases  non-conducting  substances  are  required  as  inter- 
mediates between  the  pulpal  wall  and  the  metal  filling.  In  many 
other  cases  the  metal  filling  may  be  placed  directly  upon  the  dentin 
without  danger.  In  some  cases  a  simple  layer  of  non-conducting 
varnish,  such  as  "cavitine,"^  will  be  sufficient.  In  others  zinc  phos- 
phate or  gutta-percha  must  be  added.  The  degree  of  the  response  to 
a  blast  of  cool  air  will  afford  a  guide  to  the  nature  of  the  intermediate 
required  if  any  be  deemed  necessary.  In  no  case  should  varnish  or 
gutta-percha  be  allowed  to  remain  in  the  portions  of  cavity  that 
support  the  covering  filling  material,  and  which  is  subjected  to  the 
force  of  mastication.  The  resilient  nature  of  such  substances  will 
cause  the  loosening  of  the  filling  and  probably  induce  mechanical 
or  infective  irritation  of  the  fibrils  and  through  them  of  the  pulp 
(Fig.  324). 

In  some  cases  the  undermined  state  of  the  enamel  wall  necessitates 
the  use  of  an  adhesive  zinc  phosphate  as  a  means  of  support  by 
replacing  the  lost  dentin,  and  in  such  the  pulpal  wall  may  be  covered 
and  so  protected  from  impact  as  well  as  from  thermal  changes. 

1  Cavitine  is  a  solution  of  trinitrocellulose  in  subacetate  of  amyl.  Gum  sandarac  in 
alcohol,  gum  copal  in  ether,  or  Canada  balsam  or  gum  dammar  or  colophony  in  chloro- 
form, about  30  grains  or  less  to  the  ounce  of  solvent  and  a  little  hydronaphthol 
added,  makes  an  antiseptic  cavity  varnish. 


THERAPEUTICS  OF  DEEP-SEATED  CARIES 


341 


Fig.  324 


The  action  of  zinc  phosphate  upon  dentinal  fibrils  and  the  pulp 
being  a  matter  of  some  doubt,  it  is  better  that  the  pulpal  wall  be 
varnished  before  it  is  introduced.  The  varnish  not  only  acts  as  an 
impervious  coating,  but  also  serves  as  an  additional  non-conductor. 
If  made  antiseptic  it  is  still  more  useful. 

After  the  cavity  is  prepared  it  is  sterilized  and  dried,  as  described 
in  the  next  stage  of  caries,  is  coated  with  varnish,  and  adhesive  zinc 
phosphate  plus  5  per  cent,  powdered  thymol 
mixed  stiff  is  packed  into  the  undercuts  and 
over  the  pulpal  wall,  and  approximately  formed. 

When  set  the  enamel  margins  are  freed  of 
cement  and  the  cement  is  excavated  to  the  form 
required.  In  some  cases  cement  can  only  be 
placed  over  the  pulpal  wall,  owing  to  lack  of  room 
for  both  cement  and  the  covering  filling.  In  such 
cases  the  combined  use  of  soft  cement  and  gold, 
such  as  ''moss-fiber"  as  a  first  portion  or  soft 
cement  and  amalgam,  is  useful.    (See  page  343.) 

In  deep-seated  caries  the  extension  of  cavity 
margins  in  such  a    manner  as  to  prevent  re- 
currence of  decay  is  demanded.    Upon  approxi- 
mal  surfaces  the  ideal  conditions  are  an  extension 
of  buccal  and  lingual  margins  to  a  point  which 
will  permit  a  contoured  metal  filling  to  have 
its  corresponding  buccal    and   lingual  margins 
well  irrigated  by  the  action  of  the  tooth-brush 
and  food  in  mastication.     Often  a  slight  alter- 
ation of  tooth  form,  together  with  contouring 
of  fillings,  accomplishes  the  end  desired  without 
undue  cutting  of  tooth  structure.    Thus  the  cervical  margin  may  be 
slightly  reduced  with  strips  or  disks  to  assume  an  absence  of  contact, 
but  the  enamel  must  not  be  totally  removed.     The  lingual  or  buccal 
margin  may  be  treated  in  a  similar  manner. 

The  cervical  margin  of  the  cavity  and  filling  are  best  protected 
when  overlapped  by  healthy  gum  tissue,  and  if  the  gum  be  ap- 
proached, should  be  so  arranged.  The  cervical  margin  should  always 
be  extended  beyond  the  contact  point  in  such  cases,  whether  carried 
beneath  the  gum  or  not  (see  p.  259).  Incisal  margins  are  to  have 
similar  consideration. 

Firm  approximal  contact  of  filhngs  or  filling  and  tooth  are  required 
to  prevent  packing  of  food  into  the  interproximal  space.  This  would 
both  injure  the  gum  and  introduce  the  fermentable  element  in  caries 
production.     The  point  of  contact  should  be  neatly  rounded  to 


Diagram  illustrat- 
ing the  use  of  pulp 
protectors:  V,      a 

layer  of  varnish;  GP, 
a  layer  of  low  heat 
gutta-percha,  or  in 
case  of  exposure  a 
layer  of  Jodoformagen, 
or  zinc  oxid  and  thy- 
mol in  which  case  the 
varnish  is  omitted; 
ZP,  zinc  phosphate; 
with  or  without  thy- 
mol added;  M,  metal 
covering. 


342  DENTAL  CARIES 

produce  a  normal  contact.  This  contact  should  be  obtained  even  if 
the  filling  must  be  overcontoured. 

An  exception  may  at  times  be  made  where  a  space  has  previously 
naturally  existed,  and  the  gum  margin  is  healthy. 

Teeth  should  never  be  joined  by  fillings  alone,  as  one  or  both  will 
usually  loosen.  If  necessary  for  the  protection  of  the  gum,  both  may 
be  crowned  and  the  crowns  united  by  solder,  or  a  staple  may  be 
placed  in  the  pulp  canals  of  the  two  teeth.  About  this  a  common 
filling  may  be  built.  It  may  be  that  gold  inlays,  locked  in  spacious 
"doll  heads"  on  the  occlusal  surfaces  of  both  teeth,  and  extending 
over  to  distal  approximal  surfaces  as  well  as  into  the  cavities,  may  be 
jomed  as  a  means  of  support.  Pinlays  may  be  used.  The  strain  upon 
such  fillings  is  very  great  when  occlusion  exists,  as  teeth  are  bodies 
vrith  indi^idual  motion  and  are  apt  to  be  pushed  away  from  the 
filling.     (See  Pyorrhea  Alveolaris  and  Gingivitis.) 

THERAPEUTICS    OF   ALMOST   EXPOSED   PULP. 

In  this  stage  of  caries  complaint  is  usually  made  that  for  some 
time  pain  has  been  produced  by  the  presence  in  the  mouth  of  cool 
or  hot  substances.  Several  classes  of  almost  exposed  pulps  may  be 
discovered  after  opening  the  cavity  and  removing  the  bulk  of  the 
decayed  dentin.  In  the  simplest  class  the  pulpal  wall  may  be  found 
sound  after  removal  of  all  decalcified  dentin.  This  makes  practically 
a  case  of  deep-seated  caries,  and  is  to  be  treated  as  such,  the  close 
approach  to  the  pulp  simply  demanding  additional  precautions  as 
to  non-conduction,  prevention  of  compression,  and  infection.  The 
cavity  is  to  be  neutralized  with  a  solution  of  sodium  bicarbonate  and 
and  dried;  over  the  pulpal  wall  "cavitin"  with  hydronaphthol  added 
or  other  antiseptic  varnish,  and  dried  again. 

I^ — Hydronaphthol gr.  ij 

Alcohol gtt.  XX — M. 

Add  to  the  half-ounce  bottle  of  "cavitine." 

A  thin  wafer  of  softened  gutta-percha  is  to  be  laid  over  the  pulpal 
wall  in  such  manner  as  not  to  interfere  with  the  introduction  of 
cement.  In  place  of  these  any  of  the  pulp  capping  cements  may  be 
used  as  a  first  layer  (Fig.  324).  Adhesive  zinc  phosphate  mixed  to 
consistency  just  suited  to  the  case  may  be  pressed  laterally  into  the 
undercuts,  and  will  spread  nicely  over  the  gutta-percha  without 
pressure.  Under  no  circumstances  must  the  superstructures  depend 
upon  the  gutta-percha  base  as  a  support,  as  the  filling  may  loosen 
or  the  wall  be  broken.     (See  page  340.) 

The  operation  may  be  varied  for  cases  of  but  limited  retaining 


THERAPEUTICS  OF  ALMOST  EXPOSED  PULP  343 

periphery  by  gently  spreading  the  zinc  phosphate  over  the  varnish, 
or,  in  some  cases,  the  gold  and  zinc  phosphate  or  amalgam  and  zinc 
phosphate  combination  may  be  required. 

In  the  use  of  gold  and  zinc  phosphate  a  portion  of  crystal  gold  is 
gently  tapped  into  a  mass  of  soft,  quick-setting  cement  placed  over 
the  varnish  and  the  setting  of  the  cement  awaited.  The  gold  is  then 
condensed  and  more  added. 

With  the  amalgam  and  zinc  phosphate  combination,  after  placing 
the  gutta-percha,  varnish,  etc.,  soft  cement  plus  thymol  is  placed 
upon  one  cavity  margin,  and  a  ball  of  previously  prepared  amalgam 
is  laid  upon  it.  Pressure  upon  the  amalgam  by  means  of  a  ball  bur- 
nisher causes  the  cement  to  be  spread  over  the  cavity  wall  in  advance 
of  the  amalgam.  It  practically  inlays  the  metal  filling,  but  permits  a 
better  marginal  joint  with  the  metal.  It  has  been  called  an  amalgam 
inlay  and  deserves  the  appellation  which,  however,  has  been  pre- 
empted by  a  previously  devised  but  generally  unused  operation. 
The  margins  are  freed  of  amalgam  and  cement,  and  the  operation  is 
completed  with  amalgam.  It  also  prevents  the  shifting  and  dislodge- 
ment  in  any  degree  of  the  metal  filling  which  sometimes  occurs  in 
the  act  of  introduction,  unless  guarded  against. 

This,  of  course,  refers  to  locations  in  which  the  latter  is  indicated. 
The  cement  in  the  combination  increases  the  adhesion  and  prevents 
leakage  and  the  discoloration  of  the  walls  by  the  amalgam.  A  trifle 
of  thymol  added  to  the  cement  imparts  to  it  an  antiseptic  character 
without  impairing  its  integrity  as  a  cement. 

The  second  class  of  almost  exposed  pulp  is  that  in  which  thorough 
excavation  would  cause  exposure  of  the  pulp. 

If  the  dentin  be  of  the  disintegrated,  boggy  sort,  it  should  be 
removed  regardless  of  exposure;  but  if  it  be  simply  softened  by 
decalcification  and  be  quite  firmly  adherent  to  the  cavity  floor,  and 
particuarly  if  it  be  somewhat  thickly  distributed,  the  deeper  layers 
may  be  left  in  situ,  as  a  pulp  covering. 

In  such  cases  all  lateral  walls  should  be  thoroughly  excavated  and 
only  a  thin  layer  left  over  the  pulp  horns.  ^Vhile,  without  doubt,  the 
tubules  of  decalcified  dentin  are  liable  to  be  invaded  by  bacteria. 
Miller  has  shown  that  frequently  such  dentin  may  exist  without 
invasion.    (See  Fig.  294.) 

The  argument  that  such  dentin  contains  poisonous  products  of 
bacteria  deleterious  to  the  pulp  does  not  seem  borne  out  by  results 
in  carefully  handled  cases.    Decalcification  is  not  putrefaction. 

That  some  of  these  protected  pulps  may  die  is  a  fact  not  to  be 
disputed,  but  that  many  live  in  security  is  also  true.  Whether  such 
dentin  can  be  recalcified  has  not  yet  been  scientifically  shown,  but 


344  DENTAL  CARIES 

certain  cases  treated  with  oxychlorid  of  zinc  have  shown  evidences 
of  it,  and  Miller  records  cases  of  hardening  of  such  caries  even 
without  treatment. 

The  decision  (1)  as  to  conservation  of  a  pulp  by  this  method,  or 
(2)  excavation  to  sound  dentin  or  possible  exposure  and  treating 
that  by  capping  or  devitalization  rests  with  the  particular  practi- 
tioner who  must  decide  upon  the  character  of  the  dentin,  possible 
pulp  infection  or  the  hyperemic  or  inflamed  condition  of  the  pulp 
according  to  the  symptoms.  I  would  suggest  as  favorable,  cases 
viith  a  good  quality  of  simply  decalcified  dentin  (or,  of  course,  thin 
sound  dentin)  and  without  other  symptoms  than  reasonable  hyper- 
emia responding  to  therapeusis.  The  profession  at  large  is  begmning 
to  tm-n  to  conservation  as  an  a\'oidance  of  possible  apical  abscess  due 
to  imperfect  canal  treatment. 

The  treatment  required  for  this  dentin  is:  (1)  Neutralization  of 
the  acid  present;  (2)  saturation  with  a  permanent  antiseptic;  (3)  an 
antiseptic  non-conductive  covering. 

After  drying,  a  weak  solution  of  sodium  bicarbonate  or  ammonium 
carbonate  (diluted  aromatic  spirit)  will  accomplish  the  first  require- 
ments. The  dentin  is  then  thoroughly  diied  and  saturated  with 
"cavitine"  or  other  varnish  containing  hydronaphthol,  or  a  solution 
of  Canada  balsam  contaming  hydronaphthol,  or  thin  chloro-percha 
containing  aristol  or  iodoform,  or  the  preparation  known  as  "Jodo- 
formagen-'  may  be  spread  over  it,  or  oxychlorid  of  zinc,  the  fluid 
of  which  has  been  diluted  one-third  with  water,  may  be  used  as  a 
covering  (use  fluid,  2  drops;  distilled  water,  1  drop),  or  a  mixture  of 
zinc  oxid  and  thymol  may  be  melted  over  it. 

Williams^  suggests  that  the  decalcified  dentin  be  first  saturated 
with  absolute  alcohol  for  one  minute,  then  dried,  then  wet  with  oil 
of  cloves  for  one  minute,  then  again  dried,  after  which  the  varnish, 
etc.,  is  to  be  used.  Solution  of  sulphate  of  copper  may  be  used  to 
saturate  the  dentin,  after  which  it  should  be  dried  and  encased  in 
varnish,  etc.    This  last  only  in  posterior  teeth. 

The  use  of  these  preparations  obviates  the  necessity  of  sealing 
temporary  antiseptics  in  the  cavity,  as  they  are  in  themselves  more 
or  less  permanently  antiseptic.  The  rigid  preparations  are  most 
convenient.  Over  them  zinc  phosphate,  made  antiseptic  with 
thymol  (1  to  20),  is  packed  or  flowed,  if  pressure  be  feared  and  if 
any  doubt  exist,  the  cavity  is  temporarily  sealed  with  gutta-percha 
or  temporary  cement,  usually  a  different  color  being  employed. 
When  all  doubt  is  at  rest  the  metal  filling  may  be  placed.    In  another 

1  Items  of  Interest,  1898. 


THERAPEUTICS  OF  ALMOST  EXPOSED  PULP  345 

method,  useful  in  doubtful  cases  in  determining  the  possible  bad 
reaction  of  the  pulp,  a  quite  stiffly  mixed  paste  of  eugenol  and 
Hubbuck's  zinc  oxid  may  be  introduced  into  the  base  of  the  cavity, 
gently  pressed  to  place  with  cotton,  and  covered  with  sandarac  on 
cotton.  At  a  subsequent  sitting  part  of  it  may  be  left  as  a  reason- 
ably firm  antiseptic  foundation.  A  trifle  of  thymol  may  be  added. 
If  desired,  the  entire  cavity  may  be  filled  with  it,  or  better,  to  a 
slightly  concave  surface.  Exposed  to  the  saliva  it  hardens  to  a 
degree  sufficient  to  act  as  a  cement  temporary  filling  for  weeks  or 
months,  or,  occasionally,  even  years.^  This  method  has  a  slight 
objection  in  that  one  is  liable  to  remove  all  the  material  while  exca- 
vatmg  a  part;  so  that  the  writer  prefers  in  most  cases  to  perma- 
nently apply  Jodoformagen  or  its  equivalent  and  then  cover  with 
good  adhesive  zinc  phosphate  plus  thymol  as  a  lining,  then  place 
gutta-percha  base  plate.  The  judgment  proving  correct  upon  test, 
the  balance  of  the  work  proceeds  after  removal  of  the  gutta-p'ercha. 

In  some  cases  of  deep-seated  caries  in  which  gold  filling  is  desirable, 
but  in  which  linings  are  contra-indicated,  yet  in  which  immediate 
filling  with  metal  would  involve  such  thorough  excavation  as  to 
endanger  pulp  vitality  either  as  the  result  of  excavation  or  subsequent 
thermal  shocks,  oxychlorid  of  zinc  may  be  placed  in  the  peripherally 
prepared  cavities,  and  over  considerable  masses  of  decalcified  dentin. 
If  allowed  to  remain  for  several  months  (three  to  six)  the  oxychlorid 
stimulates  the  pulp  to  the  formation  of  some  secondary  dentin,  and 
complete  excavation  to  a  sound  basis  may  be  made.  There  is  also 
some  evidence  of  hardening  of  the  dentin.  This  method  is  open  to 
the  possible  objection  that  secondary  dentin  is  a  source  of  future 
trouble,  but  the  method  has  its  advantages  in  badly  decayed  anterior 
teeth.2  In  very  deep  cavities  the  fluid  of  the  oxj'chlorid  should  be 
diluted  one-third  with  distilled  water  for  the  first  portion. 

In  these  cases  porcelain  inlays,  with  their  underlying  cement, 
should  have  due  consideration  as  therapeutic  means. 

In  deep  and  very  deep-seated  caries,  in  situations  in  which  dis- 
coloration is  not  of  great  moment  jodoformagen  may  be  placed 
over  the  pulpal  wall,  avoiding  the  bearings  and  the  cavity  filled  with 
oxyphosphate  of  copper  for  its  antiseptic  value.  The  cavity  may  be 
entirely  filled  with  it,  or  it  may  be  used  as  a  combination  with 

1  Dr.  S.  Blair  Luckie. 

2  In  some  cases  of  this  sort  seen  by  the  writer,  and  observed  for  from  ten  to  twenty 
years,  the  ill-results  of  oxychlorid  of  zinc  claimed  have  not  been  observed.  In  one  case, 
after  sixteen  years,  a  lateral  incisor  crown  broke  off,  and  the  pulp  was  found  to  have 
receded,  but  was  otherwise  apparently  healthy.  The  question  is  one  of  the  advisability 
of  immediate  de-vitaUzation,  with  its  advantages  and  disadvantages  in  anterior  teeth, 
or  of  a  possible  remote  pulp  death,  etc. 


346  .  DENTAL  CARIES 

amalgam.  Copper  amalgam  alone  ordinarily  becomes  disintegrated 
and  caries  recurs.  Occasionally  it  lasts  well  (especially  Sullivan's); 
copper  and  its  salts  are  germicidal  in  a  short  time.  The  ordinarily 
good  behavior  of  somewhat  doubtful  dentin  under  it  is  thus  explained. 
To  make  the  filling  more  lasting  ordinary  amalgam  may  be  added 
to  a  lining  of  copper  amalgam  after  the  margins  are  freed  or  at 
least  the  copper  amalgam  feather  edged. 

Dobrzyniecki^  (Budapest),  in  eight  experimental  cases  upon 
microscopically  sound-looking  dentin,  claims  to  have  found  the 
Bacillus  gangrense  pulpse  vital  after  months  of  enclosure  under 
sealed  dressings  of  camphor,  concentrated  carbolic  acid,  or  eucalyp- 
tus oil.  All  other  organisms  were  devitalized.  As  Arkovy's^  experi- 
ments showed  the  decided  influence  of  carbolic  acid  over  this 
organism,  and  as  root-canal  antiseptics  are  nearly  always  successful 
in  cases  of  moist  gangrene  of  the  pulp  (Bacillus  gangrense  pulpse 
Arkovy),  the  difficulty  of  destroying  this  germ  by  germicides  left 
indefinitely  in  the  cavity  must  be  accepted  with  reservation. 

In  some  desperate  cases  with  the  walls  frail,  the  cements,  either 
zinc  phosphate  or  so-called  silicate  cements,  or  oxyphosphate  of 
copper  cements,  may  be  used  as  a  last  resort  before  crowning.  The 
silicate  cements  are  less  soluble  in  the  acids  contained  in  saliva  or 
formed  from  carbohydrates  against  the  filling  than  are  the  zinc 
phosphates. 

Hinkins  and  Acree^  claim  that  one-fifth  of  1  per  cent,  is  sufiicient 
to  dissolve  the  zinc  phosphate,  and  that  enough  acid  elements  enter 
from  the  blood  to  affect  it. 

The  silicate  cements  dissolve  more  readily  under  friction  than 
under  the  action  of  acid,  so  that  of  two  fillings  the  one  which  is  not 
exposed  to  attrition  or  brush  action  is  usually  in  better  condition 
after  about  two  years.  Much  care  is  necessary  to  prevent  the  dis- 
coloration of  silicate  cements. 

These  conservation  methods  apply  only  when  it  is  considered 
proper  to  conserve  a  reasonably  healthy  pulp.  Certain  considera- 
tions of  anchorage  rendered  necessary  by  weakness  of  walls  also 
contra-indicate  pulp  conservation  as  does  also  evidence  of  profound 
pulp  disease  (which  see). 

THERAPEUTICS    OF   EXPOSED   PULP. 

The  exposure  of  the  pulp  may  be  the  direct  result  of  caries;  the 
removal  of  boggy,  disintegrated  dentin  may  produce  it,  or  it  may 

1  Soderberg  upon  Arkovy:  Dental  Cosmos,  1899.  ^  Ibid. 

3  See  Dental  Cosmos,  June,  1901,  and  March,  1905. 


THERAPEUTICS  OF  EXPOSED  PULP  347 

be  the  result  of  the  removal  of  a  last  layer  of  decalcified  dentin 
or  of  the  careless  or  inadvertent  perforation  of  sound  dentin  by 
instruments.  Fracture  or  abrasion  are  occasionally  responsible  for 
exposure.    Erosion  rarely  causes  it. 

Diagnosis. — After  excavation  of  the  cavity,  washing  with  tepid 
water,  and  moderate  drying,  direct  vision  or  a  reflected  image  in  the 
mouth  mirror  may  reveal  the  area  of  exposure  as  a  round  opening 
occupied  by  a  pinkish  or  red  body.  If  the  exposure  be  reasonably 
large,  pulsation  of  the  red  body  may  sometimes  be  observed.  The 
exposure  may  be  so  slight  as  to  be  invisible,  the  depth  of  the  cavity, 
however,  indicating  that  exposure  probably  exists.  Bleeding  is  a 
certain  guide,  but  bleeding  from  the  gum  margin  must  be  borne  in 
mind.  Truman  advises  that  finely  carded  cotton  be  gently  passed 
over  the  cavity  walls,  exposure  being  detected  by  the  momentary 
pain  produced  when  the  fibers  pass  over  the  area  of  exposure. 

As  this  test  may  fail,  in  cases  of  known  exposure,  it  is  not  altogether 
reliable,  but  is  fairly  so  when  pain  is  produced,  though  hypersensitive 
dentin  must  be  borne  in  mind. 

A  finely  pointed  probe  may  be  gently  dragged  over  the  pulpal 
wall  and  catches  in  the  orifice  of  exposure,  however  small.  A  slight, 
quick  start  upon  the  part  of  the  patient  is  usually  elicited.  This  may 
consist  simply  of  a  winking  of  the  eyelid.  Flagg  warned  against 
requesting  an  affirmative  nod  by  the  patient,  as  this  would  cause 
injury  to  the  pulp.  Delicately  used,  this  test  is  the  most  reliable  in 
all  classes  of  cases,  and  is  not  painful. 

It  is  to  be  remembered  that  disease  may  have  caused  a  loss  of  a 
portion  of  a  pulp  horn,  in  which  case  the  cotton  test  will  fail;  gentle 
exploration  will  detect  the  amount  lost.  Blood,  or  pus  followed  by 
blood,  or  sensation  after  entering  the  horn  of  the  pulp  cavity,  are 
evidences  of  exposure. 

Excruciating  pain  following  mastication,  or  pressure  or  suction 
exerted  upon  the  cavity  by  means  of  the  tongue,  are  subjective  symp- 
toms indicating  a  probable  diagnosis  of  exposure.  Increase  of  pain, 
or  throbbing  pain  following  the  use  of  salt,  sweet,  or  acid  foods,  is 
fairly  indicative  of  a  practical  exposm-e,  but  the  indication  must  be 
confirmed  by  other  tests. 

Treatment. — An  exposed  pulp  is  either  to  be  capped  or  removed 
and  the  canals  filled. 

The  consensus  of  opinion  is  that  ordinarily  all  pulps  should  be 
removed,  except  those  freshly  exposed  by  removal  of  simply  decal- 
cified dentin  and  by  accident  and  those  in  teeth  with  incomplete  roots. 
There  is  no  certainty  that  pulps  exposed  by  caries  or  practically  so 
will  live  under  capping  materials,  but  the  attempt  may  be  made 
at  times  for  special  reasons. 


348  DENTAL  CARIES 

Freshly  exposed  pulps  may  be  capped  or  removed.  Perhaps  a  good 
rule  would  confine  capping  to  anterior  teeth  of  the  better  grades  in 
patients  in  good  physical  condition,  and  to  pulps  in  teeth  having 
incomplete  roots.  At  present  all  mmecessary  pulp  devitalization 
should  be  avoided  in  view  of  possible  abscess.  The  advantages  of 
capping  are  maintenance  of  tooth  translucency  and  the  avoidance 
of  canal  work. 

The  disadvantages  are:  (1)  Possible  death  of  the  pulp  by  hyper- 
emia due  to  conduction  of  thermal  changes.  (2)  An  overproduction 
of  secondary  dentin,  the  production  of  pulp  nodules,  or  other  degen- 
erative changes,  the  pulp  becoming  exhausted  and  death  ensuing. 
Increased  difiiculty  of  canal  treatment  may  result.  (3)  Disease  of 
the  pulp  due  to  infection  beneath  the  capping  material.  (4)  The 
time  required  for  assurance  of  success  or  failure. 

The  object  sought  in  capping  is  the  protection  of  the  pulp  from 
thermal  changes,  infection,  and  compression,  as  either  is  fatal  to  pulp 
vitality.  This  is  best  accomplished  by  placing  in  contact  with  the 
pulp  an  antiseptic  paste  beneath  a  metal  cap,  or  an  antiseptic 
cement  having,  when  set,  suflacient  rigidity  to  permit  other  work 
to  be  done.  In  the  latter  case  the  capping  material  may  be  spread 
over  the  pulp  by  means  of  an  instrument  or  be  carried  on  oiled  paper 
which  may  be  stripped  off  after  the  cement  has  set.. 

Prognosis  is  favorable  for  the  cases  selected  as  suggested. 

Pulp  Capping. — The  metal  cap  should  be  made  of  platinum  or  gold 
for  anterior  teeth.  Tin,  lead,  copper  or  silver  may  be  used  poster- 
iorly. After  punching  or  trimming  to  shape  it  should  be  made  con- 
cavo-convex by  pressing  it  into  soft  wood  by  means  of  the  rouuded 
end  of  an  instrument  handle.  A  film  of  wax  is  placed  on  the  convex 
side;  a  warmed,  small  burnisher  is  attached,  and  the  cap  is  adjusted 
in  proper  position  by  trying  in  the  cavity.  It  is  then  to  be  filled  with 
the  capping  material  (a  little  of  the  latter  placed  in  any  depression 
at  the  point  of  exposure  in  order  to  exclude  air) ;  then  one  side  of  the 
cap  is  laid  upon  the  dentin  and  the  other  gradually  brought  down, 
and  the  edges  of  the  cap  firmly  adapted  to  the  dentin.  This  causes 
the  paste  to  exude  from  beneath  the  cap.  Any  excess  is  gently 
removed  with  an  excavator  if  not  of  an  immediately  setting  paste. 
A  little  soft,  quick-setting,  zinc  phosphate  cement  plus  thymol  or 
oxychlorid  of  zinc  cement  is  now  run  over  the  floor  as  a  protection 
and  when  set  more  stiffly  mixed  zinc  phosphate  plus  thymol  is  used 
as  a  lining  and  this  covered  with  gutta-percha  or  temporary  cement. 
This  is  then  allowed  to  go  as  a  test.  Later  a  partial  excavation 
of  the  cement  is  done  or  better  zinc  phosphate  or  silicate  cement 


THERAPEUTICS  OF  EXPOSED  PULP  349 

placed,  or  gutta-percha  used  as  a  further  test,  which  is  allowed  to 
remain  a  year. 

These  may  be  renewed  as  worn  out  if  desirable,  or  a  portion  of 
the  covering  filling  may  be  cut  away  and  metal  introduced  to  com- 
plete the  operation.  In  all  cases  capping  materials  are  not  to  be 
allowed  to  support  the  superjacent  filling  materials  which  should 
have  their  own  support  upon  the  cavity  walls  as  shown  in  Fig. 
324.  In  case  a  plastic  filling  is  desirable  in  any  event,  the  opera- 
tion is  to  be  completed  at  the  time  of  capping  or  at  a  subsequent 
sitting. 

The  materials  used  with  success  as  pulp  cappers  are: 

1.  A  mixture  of  eugenol  and  zinc  oxid  (equal  parts  of  carbolic 
acid  and  oil  of  cloves  may  be  used  as  the  menstruum).  Hubbuck's 
zinc  oxid  or  cement  powder  may  be  used.  This  is  mixed  to  a  con- 
sistency which  will  flow,  yet  set  after  some  hours  or  days. 

2.  Oxysulphate  of  zinc,  the  fluid  of  which  is  a  saturated  solution 
of  zinc  sulphate  in  water.  The  powder  is  uncalcined  zinc  oxid.  This 
will  make  a  thin,  creamy  paste  which  flows  readily  and  sets  quickly. 
A  trifle  of  aristol,  iodoform,  or  hydronaphthol  may  be  added  to  any 
setting  cement. 

3.  Plaster  of  Paris  mixed  with  a  1  per  cent,  solution  of  formaldehyd 
in  water  will  make  an  antiseptic,  quick-setting  paste. 

4.  "  Jodoformagen."  This  substance  is  said  to  have  a  mixture  of 
eugenol  and  carbolic  acid  for  the  fluid,  while  the  powder  is  of  zinc 
oxid,  containing  paraform,  the  solid  form  of  formaldehyd.  It  also 
contains  salts  of  iodin.  A  cement  is  formed  which  sets  quickly, 
and  must,  therefore,  be  made  very  thin  when  placed  in  the  cap. 
This  material  has  been  successful  as  a  capper  even  in  exposures  by 
caries,  owing  to  its  intense  germicidal  power.  It  is  claimed  that 
the  formaldehyd  penetrates  the  tissue  of  the  pulp  for  a  distance, 
yet  permits  its  return  to  normality. 

5.  Oxychlorid  of  zinc,  with  the  fluid  diluted  with  50  per  cent,  of 
distilled  water  (1  to  2),  will  cap  successfully.  It  is  well  to  add  a  little 
powdered  thymol  to  lessen  irritation  and  add  antisepsis. 

6.  Crystallized  thymol  can  be  gently  melted  on  the  end  of  a 
burnisher  and  dropped  on  the  point  of  exposure  to  crystallize,  or 
a  piece  of  a  mixture  of  thymol  and  zinc  oxid,  made  by  melting  the 
former  and  incorporating  the  latter,  may  be  added  to  the  drop  of 
thymol  in  position  and  melted  with  a  warm  burnisher.  Setting 
cappers  may  be  used  without  metal.  Of  these  capping  materials 
the  writer  prefers  jodoformagen,  which  though  proprietary,  has  posi- 
tive sedative  as  well  as  germicidal  and  persistent  antiseptic  value. 


350  DENTAL  CARIES 

Results  of  Capping. — If  pain  be  initiated  when  the  cap  is  placed 
and  recur  later,  compression  has  occurred,  and  the  capping  must  be 
removed,  the  pulp  quieted,  and  the  capping  renewed  or  the  pulp 
removed.  Though  no  sensation  be  produced  at  the  time  of  operation, 
a  reaction  to  thermal  changes  may  occur.  If  this  gradually  subside 
as  counter-irritants  are  used,  a  diagnosis  of  arterial  hyperemia  (aseptic) 
is  confirmed.  If  the  reaction  increase,  the  heat  become  more  irri- 
tating than  cold,  and  if  at  the  same  time  paroxysms  of  pain  or  reflex 
pain  occur,  the  diagnosis  is  that  of  venous  hyperemia  or  infective 
inflammation,  according  to  the  character  of  the  symptoms,  and  the 
pulp  must  be  removed.  In  cases  of  incomplete  roots  the  large  fora- 
men prevents  the  formation  of  a  venous  stasis.  Even  if  the  pulp  be 
kept  alive  only  until  root  completion,  much  good  will  be  done. 

A  pulp  may  remain  quiescent  for  weeks  or  months  and  then  un- 
favorable symptoms  set  in,  or  it  may  die  without  any  apparent  pain. 
It  is  probable  that  in  the  latter  case  some  reflex  pains  have  been  felt, 
but  not  related  with  the  tooth,  in  the  mind  of  the  patient. 

In  the  successful  cases,  either  the  orifice  of  exposure  is  covered 
over  by  a  deposit  of  secondary  dentin,  or  the  pulp  remains  perfectly 
quiescent  beneath  the  capping  material,  without  formation  of  deposit. 

Even  when  a  deposit  occurs  the  pulp  may  die  from  the  atrophy 
and  degeneration  attendant  upon  the  formation  of  much  secondary 
dentin,  and  when  no  deposit  occurs  infection  following  leakages 
about  filling  and  capping  materials  may  take  place  after  years  of 
apparent  success.  While  capping  may  be,  and  has  been,  successful 
in  all  grades  of  exposure,  there  is  no  certainty  of  success  in  the 
exposure  by  caries.  The  tentative  treatment  necessary  offsets  the 
labor  of  canal  treatment.  The  alternative  to  capping  the  pulp  is 
its  removal.     This  requires  a  special  chapter  (which  see). 

THERAPEUTICS    OF   PERFORATION   BY   CARIES. 

The  progress  of  secondary  caries  in  the  dentin  about  the  pulp 
chamber  hollows  out  the  root  until  at  least  at  one  point  the  chamber 
wall  is  but  a  decalcified  layer  of  cementum  covered  by  decomposing 
dentin.  At  some  point  the  pericemental  tissue  will  be  uncovered  by 
excavation  or  by  the  carious  process  (Fig.  325).  The  crown  will 
probably  be  badly  decayed.  Taking,  as  an  example,  a  lower  molar 
perforated  at  the  bifurcation  with  the  pericemental  tissue  hyper- 
trophied  into  the  opening  (fungous  gum),  its  treatment  may  be 
described  as  follows:  The  gum  is  first  to  be  pressed  out  with  cotton 
medicated  with  an  antiseptic  solution  or  varnish.  Fletcher's  car- 
bohzed  resin,   or  aristol  in  chloroform,   or    sandarac  varnish  plus 


THERAPEUTICS  OF  PERFORATION  BY  CARIES 


351 


orthoform,  will  serve.  The  patient  may  assist  by  placing  daily 
cotton  pellets  saturated  with  any  of  the  mild  aqueous  antiseptics, 
pliers  being  furnished  for  the  purpose. 

If  immediate  work  be  desired,  polypoid  fungous  gum  may  be 
saturated  with  trichloracetic  acid  and  cut  away  without  much  blood- 


FiG.  326 


Diagram  of  treatment  of  perforation 
by  decay. 


Crowning  of  divided  roots.   (Evans.) 


letting  by  means  of  a  large,  sharp,  spoon  excavator,  or  novocain 
or  ethyl  chlorid  may  be  used  for  local  anesthesia  or  an  electric  cautery 
may  be  used.  Large,  rose-head  burs  are  used  to  free  the  cavity  of 
all  decay.  The  canals  are  opened  and  treated.  If  further  treat- 
ment be  desired,  or  be  impossible  until  the  perforation  is  disposed 


Fig.  327 


Fig.  328 


Cantilever  crown.  The  useless  root 
should  be  extracted.    (Evans.') 


Diagram  of  a  lateral  perforation  treated  with 
gutta-percha;  successful  for  seven  years,  when 
breakage  of  the  crown  occurred  including  the 
perforation:  GP,  gutta-percha;  OZ,  oxychlorid 
of  zinc;  A,  amalgam. 


of,  metal  or  wooden  pegs  (the  Downie  broach  reamers  will  serve) 
are  placed  in  the  canals  and  a  reasonably  thin  layer  of  copper  amal- 
gam is  built  about  the  pins  and  over  the  perforation.  A  slight 
movement  of  the  pegs  will  permit  their  withdrawal,  leavmg  open- 


1  Artificial  Crown  and  Bridge-work. 


352  DENTAL  CARIES     . 

ings  in  the  amalgam  through  which  the  treatment  may  be  subse- 
quently conducted.  The  amalgam  is  then  allowed  to  harden  (Fig. 
325).  To  carry  on  the  treatment  while  hardening,  formocresol  on 
a  cotton  pellet  may  be  inserted  over  the  openings  in  the  amalgam 
and  sealed  over  with  soft  cement. 

After  canal  filling  the  canals  may  be  further  reamed  for  screws  or 
pins,  which  are  inserted  and  the  operation  completed  with  amalgam, 
or  zinc  phosphate  and  amalgam  if  the  condition  of  the  crown  admit 
of  it;  or,  if  crowning  be  required,  this  is  arranged  for  in  the  building 
up  with  amalgam. 

A  long  perforation  at  a  bifurcation  may  practically  divide  molar 
roots.  This  is  to  be  made  a  complete  division  after  treatment  of  the 
canals.  Each  section  may  be  fitted  with  a  pin  and  amalgam  stump, 
to  which  a  gold  barrel  is  fitted.  The  barrels  are  each  given  an  occlu- 
sal face,  or  the  two  a  common  occlusal  face,  and  soldered  together 
(Fig.  326). 

If  one  root  be  unsuitable  it  may  be  extracted  and  the  other  used 
as  a  foundation  for  a  cantilever  crown,  a  spur  from  which  rests 
slightly  upon  the  occlusal  face  of  the  adjoining  tooth  (Fig.  327),  or 
the  crown  may  carry  a  spur  which  rests  in  an  inlay  or  filling  in  the 
adjoining  tooth. 

A  smooth  plaque  of  low-heat,  white  gutta-percha  (not  temporary 
stopping)  makes  an  excellent  covering  for  a  perforation.  It  is  made 
larger  than  the  opening  covered,  warmed,  pressed  to  place,  and  the 
edges  sealed  with  a  hot  burnisher.  The  covering  filling  will  retain 
it  in  position.  The  approach  to  the  perforation  should  be  widely 
funnelled  to  permit  a  ready  adaptation.  A  splendid  covering  for 
accessible  perforations  is  found  in  oxyphosphate  of  copper  cement. 
The  opening  should  be  funnelled,  the  parts  dried  thoroughly  and 
the  cement  properly  mixed  can  be  painted  over  the  orifice,  adhering 
tenaciously  to  the  tooth  and  soft  tissue  without  pressure.  It  exer- 
cises an  antiseptic  influence.  If  sepsis  occur,  the  resulting  abscess 
will  occur  opposite  the  perforation,  or  in  some  cases  create  a  small 
pocket  similar  to  a  pyorrhea  pocket.  In  all  cases  judgment  must 
be  exercised,  and  the  attempt  to  conserve  unsuitable  cases  avoided 
(Fig.  328). 

THERAPEUTICS    OF   LOSS    OP   CROWN   BY   CARIES. 

If  the  portion  of  crown  left  after  excavation  be  self-sustaining, 
but  incapable  of  retaining  a  filling  in  the  cavity,  pins  or  screws 
may  be  placed  in  the  root  canal  or  the  pulp  cavity  may  be  enlarged 
and  made  retentive.    A  filling  is  then  b^ilt  about  or  into  the  anchor- 


THERAPEUTICS  OF  LOSS  OF  CROWN  BY  CARIES         353 

age  so  made.  At  times  the  remainder  of  a  tooth  crown  will  support 
a  hollow  metal  crown. 

When  the  carious  crown  has  broken  away  or  filling  has  become 
practically  impossible  or  undesirable,  the  original  beauty  or  useful 
form  of  the  tooth  may  be  approximately  restored  by  means  of  one  of 
the  many  forms  of  dowelled  porcelain  crowns,  specially  constructed 
gold  and  porcelain  crowns,  or  all-gold,  hollow-metal  crowns,  or  a 
broad  band  may  be  adjusted  and  filled  in  with  amalgam  after  setting 
with  cement,  or  where  a  portion  of  crown  only  remains  soft  amalgam 
may  be  used  inside  of  the  band  to  make  the  adaptation,  and  the  band 
then  filled  in,  completing  the  work  on  the  side  at  which  the  band 
has  no  cervical  adaptation.  These  operations  have  been  successful 
for  years,  if  the  remnant  of  crown  has  any  supporting  ability. 

If  an  anterior  root  be  so  hollowed  out  by  caries  as  to  be  incapable 
of  supporting  a  dowelled  crown,  with  or  without  a  cast  base,  it  may 
be  extracted,  and  the  operation  of  transplantation  performed,  or, 
later,  an  implantation  may  be  made. 

In  the  former  operation  the  existing  alveolus  is  enlarged  if  necessary 
to  accommodate  a  tooth;  in  the  latter  operation  a  new  alveolus  is 
created  by  means  of  appropriate  trephines  and  bone  reamers.  The 
tooth  is  to  be  prepared  as  for  replantation  (which  see).^ 

If  teeth  have  been  lost  by  extraction,  the  spaces  created  may  be 
filled  by  means  of  bridge-work  or  plates  of  various  sorts. 

By  common  consent  crown  and  bridge-work  is  considered  a 
special  department  of  dentistry. 

Therapeutics  of  Loss  of  Roots  by  Caries. — -This  occurs  in  several  ways: 

1.  After  loss  of  the  crown  and  the  extension  of  the  carious  process 
into  the  interior  of  the  root.  In  the  later  stages  this  root  is  rendered 
valueless  for  crowning  purposes,  and  should  be  extracted.  In  some 
cases  a  transplantation  operation  would  be  warrantable,  as  in  case 
of  a  single  incisor,  the  other  teeth  being  relatively  sound.  (See  above.) 

2.  If  an  artificial  crown  has  been  so  placed  as  to  expose  the  joint 
to  caries,  the  process  may  proceed  to  a  considerable  extent,  but 
does  not  necessarily  involve  the  root  interior,  owing  to  the  presence 
of  the  pin.  Filling  with  amalgam  or  other  plastic,  or  the  recrowning 
is  demanded  if  feasible.  The  gum  having  grown  in,  much  packing 
out  may  be  required;  ablation  may  be  required  as  well. 

3.  In  some  cases  penetrating  cervical  caries  will  cause  a  partial  or 
complete  amputation  of  a  lingual  or  buccal  root  of  an  upper  molar, 
or,  possibly,  a  bicuspid.  The  pulp,  of  course,  will  have  died,  at 
least  at  the  carious  area. 

1  For  methods  of  implantation,  see  special  chapter. 
23 


354 


DENTAL  CARIES 


Fig.  329 


The  cavity  of  decay  should  be  cleansed  and  undercut,  and  an 
occlusal  tap  made  for  free  entrance  to  the  canals.    The  canals  are  to 

be  reamed  with  Kerr  broaches.  The  canal 
of  the  decayed  root  is  to  be  enlarged  with 
Kerr  root  reamers,  after  which  everything 
is  to  be  dried;  a  canal  probe,  or  the  largest 
reamer  used,  which  may  have  wax  in  the 
spaces  between  the  blades, is  passed  through 
the  tap  across  the  cavity  into  the  farther 
portion  of  the  root  canal.  Good  amalgam 
is  to  be  thoroughly  packed  into  the  cervical 
cavity  and  hardened  by  wafering.  When 
nearly  set,  the  filling  is  supported  against 
dislodgement  and  the  canal  probe  is  care- 
fully withdrawn.  After  appropriate  steri- 
lization of  canals  with  formalin  solutions, 
the  canal  is  filled.  If  the  decay  has  been 
severe,  and  fracture  threatens,  an  iridio- 
platinum  pin  is  to  be  fitted  into  the  involved  canal  and  the  crown 
tap  and  the  pin  used  as  the  canal  former  while  filling  the  cavity 
and  then  withdrawn.  Later  after  sterilization  it  is  cemented  into 
the  canal,  thus  strengthening  the  root  against  a  threatened  fracture. 
If  actually  separated  by  decay,  it  is  better  to  extract  the  separate 
root  portion  and  trim  the  stump,  as  in  ordinary  root  amputation. 
(See  special  chapter.) 


Method  of  restoring  lost 
canal  continuity.  The  cavity 
should  have  more  retention 
form  than  shown,  a,  amalgam. 


CARIES    OF    THE    TEMPORARY   TEETH. 

Caries  of  the  temporary  teeth  differs  but  little  from  that  of  the 
permanent  teeth.  The  pulp  cavities  are,  however,  relatively  larger, 
and  the  intensity  of  the  carious  process  often  causes  rapid  exposure 
of  the  pulp.  Owing  to  the  flat  character  of  the  approximations  of 
the  teeth,  there  is  often  more  approximal  than  occlusal  caries,  and 
the  cavities  often  have  weak  peripheries. 

Children  have  a  fear  of  dental  offices,  excited  by  unpleasant  experi- 
ences or  the  talk  of  their  elders,  and  they  do  not  mention  slight  pain 
such  as  that  excited  by  hypersensitive  dentin.  There  is,  however, 
abundant  evidence  that  the  dentin  of  the  temporary  teeth  may  be 
hypersensitive.  In  cavities  of  simple  nature  the  fillings  indicated 
for  adults  serve  if  the  operations  are  well  borne. 

The  shapes  of  the  teeth,  the  restlessness  and  fear  of  the  little 
patients,  and  the  free  flow  of  saliva  indicate,  for  the  most  part,  the 
use  of  plastic  fillings,  though  the  rubber  dam  may  often  be  readily 
used.    In  deep  cavities  not  exposing  the  pulps,  the  methods  employed 


CARIES  OF  THE  TEMPORARY  TEETH  355 

for  adults,  of  varnishing  or  insulating  with  gutta-percha  and  the 
subsequent  use  of  zinc  phosphate  as  a  lining  under  metal  fillings, 
are  indicated.  (See  p.  343.)  Certain  occlusal  cavities  having  small 
orifices  and  large  interiors  are  well,  and  often  permanently,  filled 
with  pink  gutta-percha.  Zinc  oxid  and  eugenol  made  into  a  stiff 
paste  often  fills  cavities  acceptably,  and  lasts  as  well  as  ors^phos- 
phate  unless  it  is  too  freely  masticated  upon. 

If  cavities  are  observed  before  pain  has  been  complained  of,  and 
prompt  and  quickly  subsiding  response  to  applications  of  cold  water 
is  obtained,  indicating  a  normal  pulp,  the  cavity 
should  be  excavated,  with  more  regard  to  re-  ^^°-  ^"^^ 

moving  the  marginal  caries  than  to  thorough 
excavation,  dried,  and  an  application  of  a  20 
per  cent,  solution  of  silver  nitrate  made  for  a 
few  minutes,  the  cavity  being  subsequently  filled 
usually  with  zinc  phosphate  or  copper  cement. 

In    cases  of  adioining   approximal    cavities         ,     ,       . 

,  .  T  ..         „  ^  IV  ^  Mode     of     prepanng 

there  is  a  disposition  tor  the  anected  teeth  to  approximal  ca^^ties. 
press  together  and  lessen  the  size  of  the  dental 
arch.  Bonwill  advised  as  a  practice,  followed  by  uniformly  good 
results  in  such  cases,  to  cleanse  the  cavities  (Fig.  330)  and  insert 
masses  of  pink  gutta-percha  base-plate.  The  constant  biting  upon 
the  gutta-percha  causes  a  separation  of  the  teeth,  which  increases 
the  size  of  the  arch  and  affords  additional  space  for  permanent 
successors.  Hollingsworth  introduced  the  idea  of  placing  a  small 
piece  or  cap  of  metal  at  the  cervix,  bridging  the  interdental  space. 
A  bit  of  gutta-percha  is  to  be  placed  on  the  under  side  of  the  cap 
to  make  a  gutta-percha  adaptation;  then  more  is  built  over  it.  Bon- 
will advised  that  before  the  gutta-percha  masses  are  inserted,  small 
pieces  of  blotting  paper  saturated  with  carbolic  acid  be  laid  against 
the  dentinal  walls  and  the  gutta-percha  be  packed  over  them.  The 
more  efficient  and  persistent  antiseptic  silver  nitrate  may  be  applied 
instead  of  the  carbolic  acid.  Kirk  advises  that  asbestos  felt  be 
heated  to  destroy  any  organic  matter  present  in  it  which  might 
combine  with  the  silver,  and  then  be  soaked  in  a  saturated  solution 
of  silver  nitrate,  dried,  and  kept  in  dark  bottles  away  from  the  light. 
Small  pieces  of  the  prepared  felt  may  be  used  as  described.  With 
cavities  as  good  as  shown  in  the  illustration,  wedging  and  contouring 
each  tooth  with  amalgam,  after  the  use  of  silver  nitrate  and  varnish, 
is  quite  admissible  after  making  suitable  retention.  There  is  no 
reason  why  occlusal  extension  for  retention  should  not  be  made. 
The  conditions  will  determine  the  choice  of  materials. 

The  silver-nitrate  method  is  particularly  applicable  to  shallow 
cavities  in  which  excavation  for  filling  is  impracticable.    The  dentin 


356  DENTAL  CARIES 

surface  is  cleansed  and  dried,  and  the  fused  silver  nitrate  is  rubbed 
upon  the  surface.  This  may  be  done  after  the  method  of  Craven: 
a  platinum  wire  is  dipped  into  the  powdered  salt  and  held  over  a 
flame  until  the  powder  fuses  into  a  button.  By  this  means  applica- 
tion can  be  directly  and  accurately  made.  The  arch  is  apt  to  become 
somewhat  contracted,  and  food  is  liable  to  wedge  between  the  teeth. 
In  most  cases  fillings  should  also  be  used.  Combination  fillings  of 
zinc  phosphate  or  oxyphosphate  of  copper  and  amalgam  are  of 
advantage  in  case  of  frail  walls.  For  the  anterior  teeth  silicate, 
zinc  phosphate,  and  gutta-percha  fillings  are  useful,  and  for  the 
posterior  ones  Ames'  oxyphosphate  of  copper  serves  a  good  purpose. 

Fig.  331 


Right  upper  temporary  molar  disked  lingually  and  filled. 

Caries  is  very  liable  to  occur  upon  the  approximal  surfaces  of  the 
second  temporary  and  first  permanent  molar.  If  the  former .  be 
found  largely  decayed  distally,  the  latter  will  usually  be  found  decayed 
on  the  mesial  surface.  Amalgam  in  cavities  well  extended  buccally 
and  lingually,  or  gutta-percha,  serves  well  until  the  second  temporary 
molar  is  lost,  when  a  good  gold  filling  may  often  be  introduced 
before  the  second  bicuspid  erupts. 

Well-contoured  fillings  must  be  inserted  in  such  a  case.  As  a 
preventive  measure  during  eruption  of  the  first  molar,  the  second 
temporary  molar  may  be  disked  to  the  form  shown  in  Fig.  331. 

If  incipient  or  simple  decay  has  occurred  on  the  two  teeth,  or 
even  the  second  molar  alone,  it  is  then  best  to  wedge  the  teeth  apart 
and  to  make  a  disk  separation  (on  the  temporary  tooth  only)  from 


RECURRENCE  OF  CARIES  357 

the  lingual  or  buccal  side,  or  both,  and  to  contour  the  filling  even  in 
exaggeration,  so  that  a  minimum  of  contact  shall  exist.  Any  sur- 
face of  dentin  exposed  by  the  disking  should  be  included  in  the  cavity, 
or,  if  this  be  not  possible,  then  it  should  be  rubbed  with  silver  nitrate. 

Such  surfaces  should  be  carefully  observed  at  regular  intervals; 
indeed,  if  prophylaxis  can  be  regularly  instituted  early  and  before 
caries  of  the  first  permanent  molar,  much  good  will  be  done. 

The  pulp  diseases  resulting  from  caries  of  the  temporary  teeth  will 
be  considered  with  those  of  the  permanent  teeth.  If  the  temporary 
teeth  be  so  badly  decayed  as  to  be  hopeless,  so  far  as  filling  is  con- 
cerned, they  should  be  extracted.  Occasionally  the  encircling  of  the 
teeth  with  pure  gold  bands  cemented  to  place,  or  filled  in  with  amal- 
gam is  good  practice. 

In  the  main  the  temporary  teeth,  especially  the  molars,  should  be 
filled  with  some  view  to  the  longevity  of  the  fillings,  as  they  often 
have  to  do  service  for  years;  malocclusion  of  the  permanent  teeth 
may  be  prevented,  and  the  general  health  of  the  mouth  is  improved. 

The  child  should  always  be  treated  with  kindness  and  truthfulness 
to  establish  faith,  yet  with  sufiicient  firmness  to  command  control. 

Under  no  circumstances  should  the  child  be  given  an  excessive 
dread  of  dental  operations,  or  be  broken  by  nervous  shock,  as  this 
attitude  defeats  the  object  sought. 

In  one  extreme  case  in  which  the  child  had  never  endured  dental 
work,  chloroform  followed  by  ether  was  given  and  fifteen  plastic 
fillings  inserted.    N2O  and  O  might  be  used  for  the  purpose. 


RECURRENCE    OF   CARIES. 

Passing  over,  as  disproved  by  Miller,  the  theory  of  Palmer,  that 
caries  recurs  about  fillings  as  the  result  of  electric  action  (see  p.  242), 
it  may  be  stated,  as  proved  by  scientific  and  clinical  experience,  that 
it  recurs  because  after  teeth  have  been  filled,  conditions  exist  which 
may  favor  the  collection  of  microbic  plaques  and  stagnant  food 
material  even  more  strongly  than  the  original  conditions,  and  that 
when  recurrence  has  been  prevented,  the  work  has  been  done  in  such 
a  manner  as  to  prevent  such  collections.  The  specific  defects  which 
favor  the  formation  of  bacterial  plaques  may  be  epitomized  as  follows : 

1.  Lack  of  approximal  contact  (food  wedging  between  teeth). 

2.  Roughness  of  the  filling  at  an  otherwise  good  approximal  contact 
point  which  menaces  the  approximating  tooth  or  the  margin  of  the 
cavity  by  causing  food  retention  and  the  spreading  of  microbic  plaques. 

3.  Unremoved  excess  of  filling  material  at  margins  producing  a 
ledge  which  collects  food,  etc.    The  edge  of  a  crown  may  act  in  a 


358  DENTAL  CARIES 

similar  manner.     i\.n  excess  well  beneath  the  gum  is  more  apt  to 
produce  gingivitis  than  caries. 

4.  Exposure  of  the  cavity  margin  due  to  lack  of  covering  by  the 
filling  material,  whether  not  properly  placed,  flaked  away,  or  due  to 
fracture  of  margin  during  the  filling  process  or  subsequently  thereto. 

5.  Exposure  of  the  cavity  margin  due  to  shrinkage  or  shifting  of 
the  filling  material.  The  use  of  material  not  enduring  mastication 
in  places  subject  to  it;  the  washing  out  of  cement  from  the  joint 
of  an  inlay  or  combination  filling  or  dowelled  bandless  crown  has 
much  the  same  effect,  though  often  much  delayed. 

6.  Solubility  of  the  filling  material,  permitting  the  cavity  wall  to 
become  exposed. 

7.  Roughness  of  tooth  surface,  produced  by  polishing  fillings  with 
rough  approximal  trimmers,  coarse  grit  strips,  disks,  or  wheels. 
Exposure  of  dentin  by  overpolishing  may  be  classed  with  the  above. 

8.  Lack  of  hygiene  of  surfaces  which  tend  to  decay,  partly  due 
to  lack  of  extension  of  cavity  margins.  Even  poor  margins,  if  well 
extended,  may  not  decay,  whereas  existing  at  or  near  contacts  they 
are  menaces.  Lack  of  extension  of  approximal  cavities  often  causes 
failure,  through  failure  to  include  all  carious  enamel.  Lack  of  exten- 
sion of  a  filling  into  a  fissure  adjoining  it,  which  fissure  may  be 
decayed  or  invite  subsequent  decay.  Lack  of  extension  of  labial 
cavities  sufiiciently  under  the  gum  cervically  and  in  the  mesial  and 
distal  direction,  leaves  a  tissue  vulnerable  to  microbic  plaques  if  not 
already  attacked  superficially. 

Treatment. — ^The  treatment  of  recurrent  caries  does  not  differ 
materially  from  that  of  primary  caries. 

Repairs  to  obliterate  crevices,  breaks,  or  new  decays  may  often 
be  made  if  seen  early,  but  so  often  is  it  the  case  that  apparently 
slight  recm-rences  are  found  after  removal  of  the  filling,  to  involve 
the  entire  cavity  wall,  that  the  only  sound  recommendation  applic- 
able to  all  cases  is  that  the  filling  be  removed  and  the  cavity  repre- 
pared  and  refilled.  The  exception  exists  when,  after  the  new  cavity 
of  decay  is  all  excavated,  the  adaptation  of  the  filling  is  seen  to  be 
perfect.  Decay  at  two  or  more  points  of  recurrence  not  subject 
to  accurate  repair,  or  general  inferiority  of  the  filling  should  condemn 
the  enthe  piece  of  work. 

PROPHYLAXIS    OF   CARIES. 

The  prophylaxis  of  caries  involves  the  removal  of  its  causes  at 
frequent  intervals.  The  condition  under  which  this  is  applicable 
and  the  prophylactic  treatment  is  fully  considered  in  the  special 
chapter  on  prophylaxis. 


SECTION  VI. 

DISEASES  OF  THE   DENTAL  PULP. 


CHAPTER  XII. 
CONSTRUCTIVE  DISEASES. 

Diseases  of  the  dental  pulp  are  both  acute  and  chronic.  Accord- 
ing to  the  anatomical  features,  they  may  also  be  divided  into  con- 
structive and  destructive.  The  acute  diseases  are  usually  destruc- 
tive; in  the  chronic,  structural  and  constructive  changes  are  com- 
monly noted. 

Pathologically  there  is  no  abrupt  line  of  demarcation  between 
diseases  of  the  dentin  and  those  of  the  pulp,  as  the  dentinal  tubules 
contain  the  fibrillar  prolongations  of  the  odontoblasts  of  the  pulp. 
Effects  produced  upon  the  fibrils  cause,  therefore,  a  pulp  reaction 
which  may  lead  either  to  a  constructive  or  destructive  activity 
according  to  the  grade  of  hj^^eremia  or  inflammation  set  up.  The 
pulp  diseases  likewise  cannot  be  sharply  defined,  as  the}'  are  to  some 
degree  interdependent.  For  example,  mild  hj'peremia  may  cause 
pulp  nodule  formation  while  the  presence  of  the  latter  may  induce 
more  severe  h}T)eremia  or  inflammation. 

CONSTRUCTIVE   DISEASES    OF    THE   DENTAL   PULP. 

The  constructive  diseases  of  the  dental  pulp  include  all  the  sec- 
ondary dentin  formations,  tubular  calcification,  the  formation  of  pulp 
nodules  and  calcareous  degeneration  of  the  pulp. 

Tubular  Calcification. — Definition. — By  tubular  calcification,  or, 
to  express  the  condition  more  accurately,  tubular  dentinification,  is 
meant  the  change  that  occurs  in  the  dentin  which  leads  to  an  obliter- 
ation of  the  dentinal  tubuli  by  deposition  of  dentinal  material  along 
the  inside  of  the  walls  of  the  tubules,  with  a  corresponding  atrophy 
of  the  fibrils.    It  is  a  sclerosis  of  dentin  analogous  to  osteosclerosis. 

Causes  and  Occurrence. — The  apparent  cause  is  a  mild  degree  of 
irritation,  not  passing  the  stage  inducing  construction  or  deposition 

(359  J 


360       CONSTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

(increased  function)  and  apparently  caused  by  direct  irritation  of  the 
fibrils,  more  particularly  through  the  action  of  thermal  shock,  brush- 
ing, mastication,  or  action  of  acids.  It  occurs  in  the  course  of  mechan- 
ical abrasion  and  erosion  of  the  teeth,  under  metallic  fillings,  and 
probably  a  modification  of  the  process  precedes  the  slow  invasion  of 
dental  caries  forming  the  so-called  transparent  zone  (see  page  290). 
It  begins  at  once  the  enamel  is  removed  from  the  dentin  at  any  point, 
and  the  dentin  subjected  to  irritation,  showing  it  to  be  due  to  a 
stimulation  of  the  whole  odontoblastic  cell  (including  its  fibrillar 
prolongation) .  It  occurs  in  some  degree  as  a  normal  vital  change  due 
to  age.  It  also  occurs  in  pyorrhetic  teeth  as  a  result  of  pulp  stimula- 
tion, and  is  the  probable  explanation  of  the  dense  polished  look  of 
dentin  often  seen  upon  removal  of  fillings  (Figs.  240,  291,  c,  and  301). 

Pathology. — The  fibril  is  lessened  in  diameter  as  the  lumen  of  the 
tubule  becomes  smaller.  There  is  sometimes  an  increased,  but  more 
often  a  lessened,  sensitivity  of  the  dentin. 

Other  phases  of  the  condition  are  discussed  under  transparency  of 
the  dentin,  to  which  the  disease  corresponds.    (See  p.  290.) 

The  altered  dentin  becomes  translucent,  acquiring  a  horn-like 
appearance,  and,  usually,  secondary  dentin  formation  begins  coinci- 
dently  with  it.  Andrews  claims  that  granules  of  calcific  matter  are 
pushed  into  the  fibrillse  by  the  odontoblasts  and  deposited  along  the 
inner  wall  of  the  tubule,  even  to  obliteration  of  them.  These  gran- 
ules give  the  color  to  abraded  dentin  in  the  region  of  the  pulp  cavity. 

Hanazawa^  recently  has  shown  that  there  is  a  slight  interstice 
between  the  fibril  and  tubule  wall  in  which  liquid  circulates.  He 
also  has  shown  mmierous  branches  from  the  fibrils  penetrating  into 
smaller  branching  tubules.  This  affords  anatomical  basis  for  Andrews' 
view  by  which  we  miderstand  calcific  matter  to  mean  calcoglobulin 
or  soft  dentinal  substance  which  may  be  regarded  in  the  light  of  a 
dentinal  plasma,  composed  of  lime  and  albumen  and  capable  of  con- 
solidating tubules  or  even  of  filling  slight  inequalities  under  fillings. 

Tubular  calcification  is,  for  the  most  part,  to  be  regarded  in  the 
light  of  an  effect  due  to  a  physiological  process.  It  may  be  regarded  as 
a  physiological  barrier  erected  against  the  progress  of  caries,  erosion, 
or  abrasion,  threatening  the  invasion  of  the  pulp.  While  it  delays 
the  disintegration  of  the  tissue,  it  does  not  prevent  it,  because  of  the 
overwhelming  character  of  the  cause,  but  if  the  cause  be  removed  it 
consolidates  the  surface  as  in  eburnation  {q.  v.)  In  the  cases  due  to 
age  or  the  irritation  produced  by  leucomain  retention,  it  is  probably 
a  local  expression  of  a  general  sclerotic  change,  the  intercellular 

1  Dental  Cosmos,  February  and  March,  1907. 


SECONDARY  DENTIN 


361 


substance  (tubule  wall)  being  formed  at  the  expense  of  the  cellular 
(fibrilU).  In  senility  the  change  in  the  dentin  may  cause  the  teeth 
to  be  almost  transparent.    It  requires  no  treatment. 


Fig.  332 


Fig.  334 


Secondary  dentin 
formed  after  exposure 
of  pulp  by  fracture 
during  extraction. 

(Tomes.) 

Fig.  333 


Bicuspid  in  which  a 
formation  of  second- 
ary dentin  has  failed 
to  obviate  perforation 
of  the  pulp  cavity  by 
resorption.       (Tomes.) 


Harding's  case  of  united  fracture.  The  uniting  material 
is  of  coarse  osseous  structure  with  numerous  lacunal  spaces. 
(Tomes.) 


Secondary  Dentin.  —  Definition.  —  By  sec-  ^^°-  ^^^ 

ondary  dentin  is  meant  a  deposit  of  dentin 
upon  the  wall  of  the  pulp  chamber,  as  the 
result  of  pulp  stimulation  after  the  pulp  has 
enjoyed  a  physiological  period  of  rest  from 
dentin  formation.  It  is  always  attached  to 
the  dentin.  It  is  generally  an  accompaniment 
of  tubular  calcification.  (See  Figs.  240,  291-p, 
and  301.) 

Causes, — The  cause  of  formation  of  secondary 
dentin  is  a  stimulation  of  the  pulp  to  increased 
functional  activity.  This  stimulus  may  be  pro- 
vided by  any  constant  irritation  of  the  dentinal 

fibrils,  as,  for  example,  when  exposed  at  necks  of  teeth,  upon  abraded  or 
eroded  surfaces,  or  within  cavities  of  decay.    The  presence  of  metallic 


Elastic  layer  of 
calcific  material  formed 
over  an  exposed  pulp. 
(From  a  case.) 


362       CONSTRUCTIVE  DISEASES  OP  THE  DENTAL  PULP 

fillings,  conductive  of  thermal  changes,  may  provide  the  necessary 
stimulus.  Gold  crowns  upon  ground-down  crowns  of  vital  teeth  have 
a  similar  effect;  the  underlying  cement  may  be  u-ritating  enough. 
The  slightly  irritative  effects  of  oxychlorid  of  zinc  used  as  a  pulp 
capping  or  as  a  cavity  lining  often  produce  much  secondary  dentin. 
A  pulp  capping  may  provide  the  stimulus  and  new  dentin  fill  the 
orifice  of  exposure.  Absolute  exposure  without  treatment  has  been 
recorded  as  productive  of  secondary  dentin.    In  two  cases  described 


Fig,  336 


Fig.  337 


Fig.  336. — Secondary  dentin  filling  the  pulp  chamber  is  a  case  of  abrasion  of  a 
cuspid  tooth:  a,  portion  lost  by  abrasion;  c,  abraded  surface;  d,  secondary  dentin, 
filling  a  portion  of  the  pulp  chamber,  and  acting  as  a  protection  to  the  pulp ;  e,  slender 
point  of  the  pulp — irregular  deposits  are  seen  on  the  walls  of  the  pulp  chamber,  as  at 
/;  Q,  cylindrical  calcifications  in  the  root  portion  of  the  pulp  chamber. 

Fig.  337. — Secondary  dentin  from  the  same  specimen  as  Fig.  336,  magnified  suffi- 
ciently to  show  the  difference  in  primary  and  secondarj''  tissue:  a,  abraded  surface 
crown;  6,  secondary  dentin;  c,  primarj^  dentin;  d,  junction  of  primary  with  secondary 
dentin;  e,  remains  of  pulp  tissue;  /,  small  oval  masses  of  calcific  material.     (Black.) 


by  Charles  Tomes,  pulps  widely  exposed  by  fracture  of  cro"^Tis  during 
extraction  covered  themselves  completely  in.  The  histological  record, 
as  seen  in  the  photomicrograph,  demonstrated  that  a  plastic  exudate 
was  first  exuded  (plasma  as  pre%'iously  defined  above),  which  later 
calcified  as  an  amorphous  mass. 

Next  an  irregular  lamina  was  formed,  and  lastly,  dentin  containing 
tubules.  It  is  to  be  inferred  that  both  the  pulp  cells  and  the  odonto- 
blasts may  take  part  in  the  process  (Fig.  332). 


SECONDARY  DENTIN 


363 


I  have  seen  one  case  in  which  a  wide  exposure  had  been  covered  in 
sufficiently  to  enable  me  to  gently  indent  the  covering,  which  was 
convex,  with  a  ball  burnisher.  Upon  removal  of  the  instrument  it 
resumed  its  original  shape,  owing  to  its  elasticity.  The  periphery  of 
the  original  exposure  was  clearly  defined  (Fig.  335).  In  another  case 
of  known  exposure  with  bleeding  the  patient  kept  eugenol  on  cotton 
in  the  cavity.    After  several  weeks  the  exposure  could  not  be  again 

Fig.  338 


>      /%!  ^  L^^i;  ^ 


a 


Dentinal  tumor  within  pulp  chamber:  A,  diagram  of  the  tooth,  with  dotted  line 
showing  the  position  of  the  section  B.  In  B  the  pulp  chamber  is  shown  in  section, 
nearly  natural  size,  showing  the  tumor  within.  C  is  an  illustration  of  the  tissue  of  the 
tumor;  a,  a,  the  primary  dentin;  6,  irregular  tubules  connecting  the  newgrowth  with 
the  primary  dentin — most  of  these  are  very  dark  and  irregular;  c,  c,  a  calcospherite 
included  in  the  mass;  d,  apparently  a  bloodvessel  calcified;  e,  calcified  tissue;  /,  a 
finely  granular  mass;  g,  a  spur  of  very  transparent  dentin.  Dentinal  tubules  appear 
at  h,  h.     (Black.) 


discovered.  Age  seems  to  be  a  cause  of  general  secondary  dentin 
formation,  but  no  doubt  certain  forms  of  irritation  are  introduced 
competent  to  produce  the  changes;  for  example,  slight  looseness  of 
teeth,  causing  a  constant  pulp  stimulation.  At  times  reflex  irrita- 
tion seems  to  be  a  competent  cause,  as  in  cases  of  partial  abrasion 
the  unworn  teeth  may  be  affected  in  equal  degree  with  the  worn 
ones.  (Black.)  For  theory  see  pages  381  and  385. 
It  is  also  true  that  any  form  of  chronic  irritation  of  the  pericemen- 


364       CONSTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

turn  of  a  tooth  may  produce  arterial  hyperemia  of  a  pulp  which  will 
lead  to  the  formation  of  secondary  dentin  or  pulp  nodule  or  both. 
Non-occlusion,  mal-occlusion,  pyorrhea  alveolaris  are  typical  ex- 
amples of  the  non-septic  and  septic  classes  of  irritation. 

Pathology  and  Morbid  Anatomy. — The  formation  is  usually  noted 
opposite  to  some  area  of  injury,  and  may  be  distinguished  from 
normal  dentin  by  its  translucency,  or  sometimes  by  its  color,  which 
may  be  a  light  brown.  The  deposit  may  be  of  fairly  regular  or 
irregular  distribution,  and  even  tumors  attached  to  the  dentin  have 
been  described  (Fig.  338). 


Fig.  339 


Fig.  340 


Fig.  339. — Illustration  of  the  narrowing  of  the  pulp  chamber  in  a  molar  (superior) 
by  the  deposit  of  secondary  dentin  resulting  from  abrasion,  showing  the  portions  of  the 
chamber  in  which  the  deposit  usually  occurs.  The  light-shaded  portion  (b)  shows  the 
original  dimensions  of  the  chamber,  which,  in  this  instance,  seems  to  have  been  pretty 
large;  a.  a  point  of  deep  abrasion;  c,  c,  remaining  pulp  chamber,  which  is  mostly 
filled  with  irregular  masses;  d,  one  of  the  root  canals.  It  will  be  observed  that  the 
narrowing  of  the  root  canal  is  within  the  original  pulp  chamber.     (Black.) 

Fig.  340. — P.D.,  primary  dentin;  S.D.,  secondary  dentin;  P,  pulp  chamber;  D,  D, 
nodules. 

Black  has  shown  that  in  the  deposits  against  normal  dentin  the 
first-formed  portion  contains  an  almost  normal  number  of  tubules, 
but  their  direction  is  sharply  changed.  As  the  deposits  become 
thicker  the  tubules  become  fewer,  and  finally  the  dentin  becomes 
amorphous  in  character  (Fig.  341.) 

Black  relates  these  appearances  with  the  gradual  atrophy  and  dis- 
appearance of  the  odontoblasts.  As  the  pulp  becomes  smaller  it 
also  necessarily  undergoes  atrophy. 

Hopewell-Smith,!  treating  of  secondary  dentin  under  the  title  of 
"Adventitious  Dentin,"  mentions  several  varieties:  (1)  Fibrillar,  or 
that  containing  tube-like  markings  finer  and  less  regular  than  in 
normal  dentin.    This  would  correspond  to  that  in  Fig.  338,  h.     (2) 


1  Histology  and  Patho-Histology  of  the  Teeth. 


SECONDARY  DENTIN  365 

Areolar,  that  containing  interglobular  spaces  formed  by  the  non- 
union of  calcospherites.  (3)  Cellular,  in  which  the  cells  of  the 
pulp   remain   encapsulated  in  the   calcifying   matrix.      (Fig.   342.) 

(4)  Laminar,   in  which  laminated  spherites  appear   (Fig.   338,   c). 

(5)  Hyalin,  having  a  granular  or  ground-glass-like  appearance  (the 
amorphous  substance  of  Black)  (Fig.  338,/).  He  regards  the  adven- 
titious dentin  as  formed  by  pulp  cells  rather  than  by  the  odontoblasts. 
In  these  cases  the  pulp  deposits  calcoglobulin  against  the  dentin. 

Apparently  in  some  of  Black's  cases  the  calcoglobulin  was  deposited 
about  preexisting  fibrillse  which  continued  to  persist  in  the  new 
formation,  the  remaining  odontoblasts  receding,  while  in  Tomes' 
cases  the  pulps  were  compelled  to  calcify  a  plastic  exudate  as  a  sort 
of  basis  for  the  beginning  of  tubule  formation.  This  is  probably  the 
case  in  formation  of  secondary  dentin  as  a  repair  of  exposure  under 
a  cap.  Black  has  shown  that  in  abrasion  the  deposit  is  more  regular 
than  in  caries,  without  doubt  due  to  the  fact  that  the  thermal  irrita- 
tion in  caries  is  more  irregular  than  the  irritation  of  the  fibrillse  by 
abrasion.  A  deposit  projecting  irregularly  from  any  point  about  the 
pulp  cavity  side  into  the  pulp  is  called  a  "dentinal  tumor"  (Fig.  338). 

The  entire  crown  may  be  removed  by  abrasion  and  in  rare  cases 
even  by  caries,  and  yet  the  pulp  be  protected.  In  some  cases  the 
protective  action  ceases  and  the  pulp  becomes  closely  approached 
or  exposed  (Fig.  214),  probably  due  to  a  cessation  of  secondary  dentin 
formation,  the  result  of  degeneration  and  loss  of  odontoblasts,  or  it 
may  be  due  to  very  rapid  wear  (a  later  stage  of  Fig.  337). 

The  mode  of  deposition  upon  the  sides  of  the  canal  in  abrasion, 
shown  by  Fig.  336,  is  quite  characteristic,  and  sometimes  annoying 
in  that  it  permits  an  unlooked-for  exposure,  which,  upon  cocain 
anesthesia,  causes  one  to  follow  a  fine  opening  for  an  eighth  of  an 
inch  or  more  before  finding  a  proper  canal. 

Deposits  in  canals  may  occur,  lessening  their  lumen  and  increasing 
the  difficulty  of  canal  exploration  (Fig.  340). 

"Secondary  growths  in  cases  of  abrasion  are  not  confined  alone  to 
the  abraded  teeth,  but  other  teeth  which  have  escaped  wear  may  be 
affected  in  equal  degree.  In  all  of  these  cases  there  is  direct  evidence 
that  the  odontoblastic  layer  has  been  stimulated  to  increased 
activity  and  produced  the  regular  secondary  deposition."^  (See 
Reflex  Hyperemia  of  the  Pulp,  p.  385.) 

In  case  of  advanced  occlusal  abrasion  the  area  representing  the 
cross-section  of  the  original  pulp  cavity  sometimes  contains  secondary 
dentin  so  transparent  that  one  seems  to  look  into  the  pulp  cavity, 

1  Black:  American  System  of  Pentistrj%  vol.  i. 


366       CONSTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

while  in  the  same  indi^ddual  other  similarly  abraded  teeth  may  have 
the  more  characteristic  opaque  deposit  which  may  even  be  of  brown- 
ish color. 

Secondary  dentin  is  very  often  accompanied  by  other  constructive 
changes  in  the  pulp — i.  e.,  pulp  nodules  and  calcareous  degeneration 
(Figs.  340  and  346). 

Miller  has  shown  that  dentin  resorption  by  the  pulp  may  be 
repaired  by  a  new  deposit  of  secondary  dentin,  which  Hopewell- 
Smith  has  shown  to  be  of  the  nature  of  cementum  (osteodentin). 
(Fig.  364.) 

■  Fig.  341 


Calcification  or  deposit  of  secondary  dentin,  resulting  from  caries  of  an  incisor: 
A,  diagram  of  section  of  incisor,  showing  caries  at  a,  and  secondary  dentin  at  b.  B, 
illustration  magnified  200  diameters,  to  show  the  tissue  of  the  secondary  dentin:  a, 
pulp  chamber;  h,  b,  secondary  dentin;  c,  primary  dentin.  It  will  be  noticed  that  the 
dentinal  tubes  in  the  secondary  dentin  gradually  disappear,  giving  place  to  a  clear 
calcification.     (Black.) 

Tomes^  describes  and  illustrates  a  peculiar  case  of  united  fracture 
occurring  in  the  practice  of  Mr.  Harding.  In  an  incisor  an  oblique 
fracture  occurred  which  entirely  separated  the  fractured  segment, 
yet  a  plastic  exudate  occurred  which,  when  calcified,  attached  it  to 
the  fixed  portion  of  the  tooth.  The  new  formation  did  not  resemble 
dentin  in  structure  (Fig.  334). 

Fig.  243  illustrates  a  case  of  repah  of. an  incisor  fractured   at  a 


1  Pental  Surgery. 


SECONDARY  DENTIN 


367 


point  well  up  beneath  the  gum,  a  condition  reasonably  insuring 
asepsis.  A  firm  reattachment  occurred.  Fig.  241  shows  the  soft 
tissues  engaged  in  such  a  repair.  I  have  seen  such  a  fracture  which 
resulted  in  pulp  death  and  the  coronal  portion  remained  i7i  situ  for 
two  years  (according  to  the  patient).  This  would  give  time  for  such 
a  plastic  exudate  to  form.  In  another  case  I  was  compelled  to 
remove  a  pulp  for  hj^eremia  two  months  after  a  fall  fractured  a 
tooth  in  this  location.  This  and  Fig.  241  shows  that  under  aseptic 
conditions  the  pulp  may  live  and  at  least  assist  in  forming  the 
attachment. 

Fig.  342 


Osteodentin:  A,  outline  of  incisor,  showing  a  narrowing  of  the  root  canal  at  b  by 
a  deposit  of  osteodentin.  B,  illustration  of  the  tissue:  a,  primary  dentin;  b,  line  of  the 
beginning  of  a  growth  of  secondary  dentin;  c,  secondary  dentin;  d,  layer  of  granular 
matter;  e,  osteodentin;  this  has  the  lacunse  at  g  and  dentinal  tubes  at  A;;  /  seems  to  be 
the  surface  of  the  osseous  deposit;  i,  irregular  crystalline  deposits;  h,  the  pulp  chamber. 
X  350.     (Black.)     (Tomes.) 


Kirk^  records  a  case  of  immediate  replantation  in  early  life,  followed 
in  old  age  by  root  resorption.  The  tooth,  when  extracted,  contained 
secondary  dentin,  which  could  only  have  formed  as  the  result  of  a 
reattachment  of  the  pulp. 

W.  H.  Trueman^  reported  that  hypersensitive  dentin  was  noted 
some  years  after  a  replantation  under  similar  conditions. 

Osteodentin. — Tomes  states  that  secondary  dentinal  deposits  may 
assume  the  character  of  osteodentin,  a  form  of  dentin  found  in  the 
teeth  of  some  animals,  in  which  the  tissue  presents  combined  char- 
acteristics of  both  bone  and  dentin.  He  cites  the  example  also  that 
elephants'  tusks  are  frequently  repaired  with  osteodentin  after  injury. 


1  Proceedings  of  the  Academy  of  Stomatology,  1902. 


2  Ibid. 


368       CONSTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

The  specimen  illustrated  (Fig.  342)  was  taken  from  a  human  case  in 
which  the  coronal  portion  of  the  pulp  chamber  was  almost  obliterated 
by  a  deposit  of  secondary  dentin.  Probably  some  of  the  pulp  cells 
have  taken  on  the  characteristics  of  osteoblasts.  Tissue  resembling 
cementum  seems  to  be  frequently  found  as  a  tissue  of  repair. 

Results  of  Secondary  Dentin. — The  formation  of  large  masses  of 
secondary  dentin  unquestionably  brings  about  a  degenerative  con- 
dition of  the  pulp  which  may  become  a  cause  of  neuralgia.  The  con- 
struction may  itself  be  the  cause  or  pulp  nodules  may  be  associated 
as  another  expression  of  construction  due  to  the  h\'peremia  induced. 
The  pulp  may  die  through  atrophy  and  degeneration,  and,  becoming 
infected,  may  produce  pericemental  irritation.  In  one  case  seen  the 
secondary  deposit  in  the  pulp  chamber  had  separated  the  canal  fila- 
ments of  the  pulp  of  a  multirooted  tooth  into  independent  pulps, 
one  of  which  was  dead  and  the  others  alive  and  undergoing  degenera- 
tion. The  specific  symptoms  were  those  of  pericementitis — i.  e., 
elongation  and  tenderness  to  percussion. 

In  another  case  of  a  first  upper  bicuspid  the  lingual  filament  was 
perfectly  covered  in  and  vital.  The  buccal  filament,  likewise  enclosed 
and  isolated,  contained  an  abscess  within  the  pulp. 

The  symptoms  complained  of,  however,  were  those  of  acute  peri- 
cemental irritation,  simulating  incipient  apical  abscess  (Fig.  371). 

In  Burchard's  case  a  molar  containing  a  deep  cavity  filled  with 
zinc  phosphate  gave  vague  pain,  finally  referred  to  the  tooth,  which 
responded  only  faintly  to  hot  applications  and  not  at  all  to  cold  ones. 
Secondary  dentin  was  found  complicated  by  calcareous  degeneration 
— i.  e.,  a  degenerated  pulp  was  present.     Fig.  340  will  illustrate. 

It  has  been  shown  by  Hopewell-Smith  that  microorganisms  may 
enter  the  pulp  by  way  of  the  spaces  or  tubes  in  adventitious  dentin. 

In  certain  cases  a  deposit  extends  well  into  a  canal,  totally  obliter- 
ating it  for  much  of  its  length.  Unless  symptoms  be  present  it  may 
ordinarily  be  left.  In  such  cases  thermal  tests  for  pulp  vitality  seem 
often  inconclusive.  The  electric  current  should  be  a  more  satisfac- 
tory means  of  diagnosis,  provided  the  dentin  be  moist.  It  may  fail, 
howe\'er,  even  though  the  pulp  is  vital.  Radiography  may  show  the 
condition  in  the  cases  of  the  larger  root  canals.  Secondary  dentin  is 
sometimes  quite  hypersensitive,  as  shown  by  attempts  at  entering 
the  pulp;  in  most  cases  it  is  quite  insensitive  until  the  pulp  is  reached. 
For  this  reason  in  attempted  high-pressure  anesthesia  in  such  cases 
one  may  often  drill  almost  to  the  pulp  or  to  it  without  the  anesthetic. 
The  pulp  is  degenerate  in  such  cases.  This  does  not  mean  that  sub- 
sequent disposal  of  the  pulp  will  be  easy.  It  is  also  difficult,  as  a  rule, 
to  force  cocain  through  secondary  dentin,  even  with  a  compound 


PULP  NODULES  369 

syringe,  and  arsenic  acts  slowly,  though  it  devitalizes  if  the  dentin 
be  sensitive.     (See  Dry  Gangrene.) 

Treatment. — Secondary  dentin  which  has  been  regularly  deposited, 
and  particularly  in  the  canals  of  anterior  teeth,  calls  for  no  treatment. 
Should,  however,  great  hypersensitivity  of  the  dentin  and  pulp,  or 
pulp  disease,  be  evident  or  inferred  from  symptoms,  the  pulp  should 
be  removed.  Canal  opening  may  involve  a  search  of  some  difficulty 
and  necessitate  the  removal  of  much  dentin.  The  canals  may  be 
much  constricted,  especially  at  that  portion  nearest  the  pulp  cham- 
ber. As  a  rule  penetration  of  this  is  usually  rewarded  by  the  finding 
of  operable  canals.  The  condition  may  be  more  or  less  complicated 
by  the  presence  of  pulp  nodules  or  calcific  degenerations  in  addition 
to  the  secondary  dentin. 

Pulp  Nodules. — Definition. — Pulp  nodules  (pulp  stones,  nodular 
calcifications)  are  masses  of  more  or  less  translucent,  calcific  material, 
apparently  the  result  of  secretion,  having  a  fairly  definite  histological 
structure  differing  from  that  of  dentin,  and  occupying  a  position 
within  the  pulp  substance  and  not  as  a  rule  attached  to  the  dentin. 
Rarely  they  are  fused  with  the  dentinal  walls  of  the  pulp  chamber, 
and  then  are  included  by  formation  of  secondary  dentin  about  them. 

Causes. — While  these  growths  may  occupy  the  pulp  chambers  of 
teeth  in  which  the  pulp  has  been  the  seat  of  direct  irritation,  their 
occurrence  is  by  no  means  confined  to  such  teeth.  They  are  found  not 
only  in  teeth  which  have  suffered  abrasion,  erosin,  and  slowly  pro- 
gressing caries,  but,  as  pointed  out  by  Black,  they  may,  and  frequently 
do,  form  in  other  teeth  of  the  same  denture  which  are  not  directly 
involved  in  the  irritation.  This  investigator  notes  that  irritation  of 
the  pulp  of  one  tooth  of  a  denture  very  frequently  causes  a  general 
hyperesthesia  (due  to  mild  reflex  hyperemia)  of  the  pulps  of  all  of 
the  teeth.  Pyorrhea  producing  tooth  movement  or  apical  peri- 
cemental irritation  can  produce  arterial  hyperemia  of  the  pulp  and 
thereby  pulp  nodules.  This  is  due  to  the  constructive  effect  of  mild 
arterial  hyperemia  which  so  far  as  is  known  is  the  probable  proximate 
cause  of  all  constructions.  Even  when  inflammation  is  present  there 
is  always  a  zone  of  arterial  hv'peremia.     (See  pages  381  and  385.) 

Secondary  dentin  and  nodules  or  pulp  hyperemia  may  occur  in 
sound  teeth  ground  for  crowns.  This  simply  indicates  a  necessity 
for  antisepsis  in  the  cement.  The  conditions  are  not  unlike  those  in  a 
cavity  of  simple  depth  and  to  the  mind  of  the  writer  do  not  necessitate 
devitalization  before  crowning,  as  most  of  the  pulps  live  unless  danger- 
ously approached  in  grinding.  When  trouble  from  nodules  has  arisen 
in  the  writer's  practice  it  has  occurred  in  teeth  previously  abraded. 
Reference  to  Fig.  337  will  show  why  grinding  may  cause  undue  pulp 
24 


370       CONSTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

approach  or  stimulation  to  be  added  to  an  already  stimulated  pulp. 
Nodules  are  found  much  more  frequently  in  the  teeth  of  middle- 
aged  persons  than  in  those  of  youth,  although  they  may  be  present 
as  early  as  the  ninth  year,  as  sho^\'Ti  by  radiography.  They  occur 
more  frequently  multiple  than  single.     Some  of  the  larger  nodules 

Fig.   343 


PN 


A  pulp  nodule  fused  to  the  parietes  of  a  pulp  cavity.  Prepared  by  grinding:  PN, 
pulp  nodule;  D,  dentin  of  the  tooth.  X  15.  From  section  by  J.  F.  Colyer.  (Hopewell- 
Smith.) 


are  evidently  formed  by  the  coalescence  of  smaller  ones.  The  num- 
ber in  a  single  pulp  varies,  usually  from  one  to  three  or  four  but 
occasionally  more.  With  a  number  of  teeth  involved  a  considerable 
aggregate  may  exist  in  a  mouth. 

Pathology  and  Morbid  Anatomy. — The  structure  of  pulp  nodules 
does  not  resemble  that  of  dentin ;  they  possess  about  the  same  degree 


PULP  NODULES 


371 


of  transliicency  and  hardness  as  secondary  dentin  and  at  times  may 
have  opaque  portions.  This  characteristic  is  also  true  of  secondary'' 
dentin  and  hypercementosis  and  may  represent  merely  the  whimsical 


Fig.  344 


Section  of  a  pulp  nodule,  showing  many  calcospherites,  as  pointed  out  by  a,  a.   (Black.) 

variations  in  calcoglobulin  make-up  or  in  histological  forms  as  seen 
in  the  varieties  of  secondary  dentin.  Outwardly  they  may  assume 
almost  any  form;  they  range  in  size  from  minute  bodies  to  a  size 
sufficient  to  almost  obliterate  the  pulp  (Figs.  340  and  346). 

Fig.  345 


Deposit  of  calcoglobulin  within  the  tissues  of  an  inflamed  pulp.  (Black.) 


A  section  of  a  nodule  exhibits  the  presence  of  a  number  of  concen- 
trically laminated  bodies,  recognizable  as  hardened  calcospherites. 
Black  found  them  to  rarely  make  up  any  considerable  portion  of  the 
bulk  of  the  nodule.     The  remainder  of  the  nodule  is  made  up  of 


372       CONSTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

structureless  material  which  may  contain  a  few  fine  tubes,  considered 
by  Hopewell-Smith  as  produced  by  the  long  fusiform  cells. 

Black  also  found  deposits  in  the  pulp  which  throw  light  upon  the 
possible  origin  of  nodules  in  some  cases,  and  to  some  extent  upon 
the  conditions  under  which  they  may  be  formed.  In  the  pulp  of 
a  second  molar  of  a  girl,  aged  fifteen  years,  in  which  there  had  been 
decided  subjective  evidences  of  pulpitis  recurring  at  intervals  for  a 
period  of  two  months,  he  found  a  mass  representing  a  pulp  nodule  in 
its  soft  state.    "  About  one-half  of  the  coronal  portion  of  the  pulp  was 

Fig.  346 


;       I'/i      '/If 


Calcification  of  the  dental  pulp:  At  A  is  shown  the  outline  of  a  lower  molar  with  a 
cavity  at  b.  The  pulp  chamber  is  much  reduced  in  size  and  filled  with  calcific  material, 
as  shown  in  B.  a,  a,  large  granular  mass  of  calcific  material,  which  is  very  transparent, 
but  finely  granular.  A  very  few  irregular  lines  are  seen  in  the  centre,  which  shghtly 
resemble  dentinal  tubes;  b,  an  erratic  growth  of  irregularly  formed  and  unusually 
transparent  dentin;  c,  line  of  the  growth  of  dentin  from  the  floor  of  the  pulp  chamber — 
the  growth  from  other  directions  is  so  perfectly  regular  as  to  leave  no  markings;  d, 
margin  of  the  ca\'itj'^  of  decay;  e,  a  bundle  of  cylindrical  forms  of  calcific  material 
extending  down  into  the  root  canal.    These  extended  to  the  apex  of  the  root.    (Black.) 


involved  in  the  inflammation;  lying  a  little  inside  of  the  layer  of 
odontoblasts  were  several  masses  similar  to  Fig.  345,  having  globular 
forms  in  their  mass  or  attached  to  their  margins.  The  globular 
bodies  present  the  laminated  appearance  of  calcospherites."  These 
masses  may  in  all  probability  be  interpreted  as  intermediate  products 
in  the  formation  of  nodules;  they  have  not  yet  become  calcified. 

A  small   nodule  may  be  made  up   of  laminated,   structureless 
material,  the  laminae  being  arranged  about  a  central  nucleus,  the 


PULP  NODULES 


373 


nature  of  which  is  not  clear,  but  may  possibly  be  calcified  dead  cells 
(Fig.  347). 

The  conditions  of  calcification  of  nodules  are  not  definitely  known. 
Hopewell-Smith^  considers  that  they  are  deposited  by  the  pulp  cells  as 
a  secretion  about  themselves,  and  that  the  cells  are  later  obliterated 
or  may  persist  in  situ  (Fig.  348).  He  also  describes  and  illustrates 
a  case  of  a  nodule  which  had  within  it  a  pulp  cavity  containing 
pulp  tissue. 

Pulp  nodules  occur,  as  a  rule,  in  the  better  grades  of  teeth  which 
show  constructive  tendencies  upon  the  part  of  the  pulp. 

Fig.  347 


A  pulp  nodule  isolated  from  the  pulp.  Shows  its  central  nuclear  formation  and 
its  concentric  lamination.  Prepared  by  grinding.  X  50.  From  collection  of  G.  W. 
Watson.     (Hopewell-Smith.) 

It  is  probable  that  in  these  pulps  the  pulp  cells  under  conditions  of 
irritation  secrete  calcoglobulin,  which  in  part  is  developed  into  spher- 
ites  and  in  part  remains  without  definite  histological  characteristics. 
This  is  not  surprising  when  we  consider  the  spherites  and  amorphous 
cement  substance  of  which  dentin  and  enamel  are  built  up.  The 
masses  are  probably  calcified  after  their  deposition.  ^^Qiatever  the 
origin  of  the  masses — ^by  cell  secretion  or  otherwise — the  histological 
record  indicates  a  gradual  increase  in  the  size  of  the  deposit.     Pres- 


1  Normal  and  Pathological  Historj-  of  the  Mouth,  1918,  ii,  p.  20. 


374      CONSTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

sure  upon  the  nerves  results  in  irritation  and  an  increase  in  pulp 
hyperemia  which  causes  the  reaction  to  thermal  changes.  Pulp 
nodules  are  usually  found  in  the  coronal  portion  of  the  pulp,  but 
sometimes  exist  in  the  root  portions,  either  free  or  embedded  in 
secondary  dentin.  If  they  obstruct  the  lumen  of  the  canal  they 
cause  interference  with  the  circulation  and  nerve  tissue  and  may 
produce  great  pain  or  pulp  death,  probably  through  profound  arterial 
followed  by  venous  hyperemia.  Bunting  calls  attention  to  the  pos- 
sibility that  the  nodule  moving  freely  in  the  pulp  may  allow  arterial 
pressure  to  raise  it,  permitting  blood  entrance,  while  the  venous 
pressure  may  return  it  to  place  and  prevent  exit  of  blood  thus  induc- 
ing continued  internal  pressure  in  the  pulp  (a  venous  hyperemia), 
thus  causing  functional  disturbance  and  pain.^  As  in  the  case  of 
secondary  dentin,  nodules  may  be  produced  by  reflex  hyperemia,  as 
they  are  quite  frequently  found  in  teeth  near  to  an  impacted  tooth. 

Fig.  348 


PIV' 


MN 


PN 


~MN 


The  formation  of  the  pulp  nodule.  Prepared  by  Mr.  Hopewell-Smith's  process. 
PA'',  pulp  nodules;  MN,  meduUated  nerve  bundles;  T,  pulp  tissue;  C,  capillary. 
X  230.     (Hopewell-Smith.) 

Symptoms. — Multiple  nodules  may  exist  in  a  dental  pulp  and  give 
rise  to  no  evident  symptoms  whatever,  as  is  shown  by  their  presence 
in  extracted  teeth,  many  of  them  free  from  caries,  and  in  which  there 
was  no  history  of  pain.    On  the  contrary,  the  pulp  of  a  tooth  may 

>  Dental  Cosmos,  February,  1912,  p.  169. 


PULP  NODULES  375 

react  persistently  to  thermal  changes  or  even  be  the  seat  of  intract- 
able pain  without  a  depth  of  carious  invasion  which  would  lead  to 
the  inference  of  acute  pulp  disease;  and  relief  only  be  secured 
through  devitalization  of  the  pulp,  which  upon  examination  may 
reveal  a  small  or  large  pulp  nodule. 

The  symptoms  attendant  upon  the  presence  of  nodules,  so  far  as 
they  can  be  made  out,  appear  to  be  of  two  types — those  associated 
with  small  and  those  with  extensive  deposits.  Reflex  pain  is  the 
common  associate  of  both. 

Small  Deposits. — While  it  is  true  that  pulp  nodules  may  often 
exist  in  apparently  sound  teeth  without  inducing  pain,  yet  the 
pulps  of  teeth  containing  them  may  become  excessively  h^'peresthetic 
under  what  are  ordinarily  mild  sources  of  irritation.  This  is  mani- 
fested, first,  through  the  contents  of  the  dentinal  tubuli;  the  dentin 
becomes  exquisitely  sensitive  and  cool  water  directed  into  a  shallow 
cavity  produces  a  paroxysmal  and  excruciatingly  painful  response 
from  the  pulp.  In  the  absence  of  direct,  extraneous  irritation  of  the 
pulp,  the  dental  symptoms  may  be  absent,  but  a  persistent,  possibly 
intermittent,  neuralgia  ma}'  be  located  at  some  distant  point.  Pain 
in  or  about  the  ear  is  a  frequent  symptom.  Occasionally  an  obstinate 
scalp  neuralgia,  with  the  existence  of  a  hj'peresthetic  spot,  appears. 
Pain  in  the  eye,  with  tenderness  over  the  supra-orbital  foramen,  is 
also  common.  Guilford^  has  reported  a  case  of  tic  douloureux  of  two 
years'  standing,  the  result  of  pulp  nodules.  The  pain  may  be  recurrent 
or  persistent.  The  results  of  neuralgic  pain  and  loss  of  sleep  conse- 
quent thereon,  may  have  serious  effects  both  mental  and  physical. 
Fortunately  in  a  single  practice  these  results  are  not  so  frequent.  If 
arsenical  applications  be  made  to  devitalize  the  pulp,  it  is  found  that 
not  only  is  intense  pain  often  caused,  but  examination  after  even  a 
week  or  more  shows  the  pulp  to  be  still  vital  and  h^-persensitive ;  and, 
in  order  to  effect  its  destruction,  repeated  applications  of  arsenic 
must  be  used.  Pressure  anesthesia  or  cataphoresis  also  is  apt  to  be 
slow  in  action. 

Large  Deposits. — In  extensive  deposits  of  pulp  nodules  the 
dentin  may  be  almost  devoid  of  sensation,  and  applications  of  heat 
or  cold,  even  in  large  cavities,  may  be  followed  by  delayed  and  faint 
pulp  response.  Such  cases,  however,  commonly  give  a  history  of 
reflex  neuralgia  and  vague  dental  pains  extending  over  a  period,  it 
may  be,  of  years.  With  some  large  deposit  the  pain  in  the  pulp  may 
take  an  opposite  course  and  be  exquisite. 

Diagnosis. — Their  diagnosis  by  means  of  the  a;-rays  is  positive 
(Figs.  349,  350,  and  351),  but  their  diagnosis  by  symptoms  may  only 

^  Private  Communication. 


376       CONSTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

be  inferential  and  confirmation  be  lacking  until  after  devitalization 
of  the  pulp  and  the  finding  of  the  pulp  nodules  in  its  substance. 

The  tardy  action  of  arsenic  is  also  observed  in  the  cases  of  large 
deposit,  it  being  frequently  necessary  to  devitalize  the  pulp  piece- 
meal, and  sometimes  the  arsenic  will  hardly  be  tolerated  at  all. 

Treatment. — Pulps  inferred  or  shown  by  a:-rays  to  contain  nodules 
should  be  removed  if  symptoms  demand  it.  If  discovered  only  in 
course  of  radiography  they  may  be  ignored.  Considering  the  possible 
difficulties  and  the  time  consumed  the  best  method  seems  to  be  con- 
ductive anesthesia  under  which  the  entire  pulp  may  be  removed 
almost  at  leisure.  In  anterior  teeth  for  the  same  purpose  nitrous 
oxid  and  oxygen  may  be  used  or  in  selected  cases  even  the  ordinary 
N2O  apparatus.  Either  of  these  or  pressure  anesthesia  in  some 
form  may  be  used  to  aid  removal  of  the  pulp  bulb  and  obtain  blood- 


FiG.  349 


Fig.  350 


iFiG.  351 


^.^ 


Pulp  nodules  in  the  radicular  and 
coronal  portions  of  the  canal.  (Radio- 
graphs by  Price.)  ^ 


First  and  second  bicuspid  roots 
filled.  Pulp  nodule  in  first  molar. 
(Radiograph  by  Lodge.) 


letting^after  which  arsenic  may  be  used  perhaps  repeatedly  as  the 
pulp  is  resistant  in  some  of  these  cases.  In  old  days  eighteen  months 
was  required  in  one  case.  (See  Chapter  on  Removal  of  the  Pulp.) 
Ottolengui^  suggests  for  difficult  pressure  anesthesia  cases  the  repeated 
applications  of  ether  on  cotton,  until  no  pain  follows,  leaving  the 
last  pellet,  spraying  with  ethyl  chlorid,  removing  the  cotton  and  pro- 
longed spraying  again  as  valuable  in  removing  the  calcifications. 

If  the  nodule  be  found  as  a  spicular  deposit  in  the  mouth  of  the 
canal,  it  may  usually  be  removed  by  teasing  it  from  side  to  side, 
first  soaking  the  part  with  a  sodium  hydroxid  solution,  or  50  per  cent, 
sulphuric  acid,  which  quickly  destroys  the  organic  matter  of  the  pulp. 

Pericemental  reactions  are  quite  apt  to  follow  the  removal  of  such 
pulps.  This  result  is  best  obviated,  if  arsenic  is  used,  by  awaiting 
the  thorough  death  of  the  pulp  filaments  before  attempting  their 


1  Items  of  Interest,  1901. 

2  Dental  Items  of  Interest,  June,  1918,  p.  494. 


CALCIFIC  DEGENERATION  OF  THE  PULP  377 

removal.  Of  course,  other  methods  are  available,  but  reactions  still 
may  occur.  It  seems  as  though  a  habit  of  irritability  were  established 
in  the  tissues.  For  this  reason,  after  pulp  removal,  it  is  well  to  seal 
a  cotton  dressing  with  campho-phenique  plus  menthol  as  a  sedative 
for  a  time.  Counterirritants  may  be  applied  to  the  gum.  (See 
Non-septic  Apical  Pericementitis.) 

Calcific  Degeneration  of  the  Pulp. — By  calcific  degeneration  is 
meant  the  infiltration  of  inorganic  matter  derived  from  the  lymph 
into  tissue  which  is  dead  or  undergoing  degeneration.  It  occurs  in 
any  part  of  the  body  in  which  the  necessary  conditions  are  present. 

Cause  and  Pathology. — The  conditions  apparently  necessary  for 
the  production  of  calcific  degeneration  are  those  which  occur  in  a 
semistagnant  blood  current.  An  acid  reaction  occurs  owing  to  the 
presence  of  an  excess  of  carbon  dioxid  and  catabolic  products,  which 
favors  deposition  of  inorganic  matter.  The  albuminous  matter  of 
the  tissue  undergoes  degenerative  changes  owing  to  the  faulty  nutri- 
tive supply  and  waste  removal.     (See  page  62). 

Fig.  352 


A,  outline  of  a  lower  molar,  with  a  large  carious  cavity  at  a;  b,  pulp  chamber; 
the  shaded  portion,  c,  was  occupied  by  cylindrical  calcifications.  B,  cylindrical 
calcifications.     X  100.     (Black.) 

Probably  some  cells  die.  They  or  their  constituents  have  some 
affinity  for  inorganic  salts  which  are  taken  up  from  the  IjTnph.  Thus 
gradually  the  tissue  becomes  infiltrated. 

Those  causes  which  produce  a  sufficient  degeneration  of  pulp  tissue 
to  induce  the  above  process  are:  (1)  The  pulp  exhaustion  due  to 
the  formation  of  secondary  dentin  or  pulp  nodules;  (2)  continued 
hyperemia  or  chronic  inflammation  in  which  venous  hyperemia  plays 
a  part. 

The  calcific  material,  unlike  the  cases  of  nodular  calcification, 
encloses  the  anatomical  elements  of  a  pulp  in  process  of  degenera- 


378       CONSTRUCTIVE  DISEASES  OF   THE  DENTAL  PULP 

tion  in  a  mass  produced  by  deposition,  not  secretion.  In  the  root 
portions  of  pulps  in  which  fibrous  elements  have  become  pronounced 
the  calcification  may  be  tubular  or  cylindrical  in  character,  the 
nature  of  the  calcareous  masses  being  apparently  a  deposition 
about  and  along  the  fibers  (Fig.  352). 

Upon  optical  examination  the  masses  are  seen  to  be  opaque,  are 
brittle,  and  decidedly  unlike  pulp  nodules  in  form.  They  may  be 
associated  with  pulp  nodules  as  an  added  and  more  advanced  degen- 
eration. The  nodules  may  also  have  opaque  portions  attached  to 
the  clearer  masses  (see  page  371).  The  pulps  are,  of  course,  living. 
There  is  a  comparative  absence  of  cellular  elements  in  the  pulp — 
i.  e.,  they  have  atrophied,  degenerated,  and  been  absorbed. 

Another  evidence  of  the  cellular  degeneration  is  seen  in  the  great 
ease  with  which  such  pulps  are  removed  after  devitalization,  even 
the  most  minute  apical  portions  freely  coming  away  after  slightly 
catching  a  hook  in  the  pulp — i.  e.,  the  usual  odontoblastic 
attachment  to  the  dentin  is  not  present.  When  extracted  these  pulps 
have  a  granular  feel  to  the  fingers,  and  when  dry  may  be  quite  stiff 
(Fig.  353). 

Fig.  353  illustrates  a  case  discovered  upon  fracture  of  a  molar 
during  the  operation  of  extraction.  In  another  case  the  pulp  was 
slightly  bendable  when  extracted,  but  after  drying  for  a  half-hour 
became  at  its  apical  end  of  needle-like  sharpness  and  stiffness.  It 
was  filled  with  calcific  granules. 

Symptoms. — Degenerations  of  the  pulp,  as  a  rule,  present  symptoms 
of  refiex  pain,  vaguely  referred  to  other  parts.    The  response  to  hot 
applications  is  usually  greater  than  that  to 
Fig.  353  ^old  ones,  and  both  are  delayed — i.  e.,  five 

seconds  or  more  may  elapse  before  pain 
follows  a  severe  test  like  the  intensely  cold 
spray  of  ethyl  chlorid  or  a  hot  copper  ball 
or  blast  of  hot  air.  At  times  with  an  open 
pulp  chamber  the  symptoms  of  chronic 
pulp  inflammation  are  obtained.  There 
may  be  a  painful  reaction  to  arsenic  applied 

Lingual  filament  of  pulp       ^q  -j-J^g  pulp. 
of  an  upper  molar,  broken  .  ,   ,»  rr^i 

in  extraction.  The  rigidity         Diagnosis  and  Treatment.— i  he  .T-rays  may 
of  the  filament  was  due  to     afford  a  positive  diagnosis  if  some  nodular 

the    presence    of    calcific  ,  ,  i     i  i  x    •       xt, 

granules.  mass   DC  present,   but  probably  not  m  tne 

more  granular  forms  as  detail  will  be  lacking 
in  the  radiograph.  In  such  cases  the  diagnosis,  apart  from  the  infer- 
ence from  the  symptoms,  is  a  postmortem  one.  In  cases  warranting 
the  interference,  in  which  there  is  a  delayed  response  to  intense  ther- 


CALCIFIC  DEGENERATION  OF  THE  PULP  379 

mal  tests  applied  to  a  filling  or  a  clean  pulpal  wall,  the  piilp  should 
be  removed  and  may  then  be  found  to  contain  the  granular  masses. 

The  constructive  diseases  of  the  pulp  are  an  evidence  of  an  attempt 
upon  the  part  of  the  pulp  to  protect  itself;  but  with  the  exception, 
perhaps,  of  a  very  regularly  deposited  secondary  dentin  the  effects 
react  upon  the  pulp  itself,  causing  its  destruction.  To  what  extent, 
therefore,  secondary  dentin  is  beneficial  is  an  open  question. 

Evidences  of  constructive  action  upon  the  part  of  the  pulp  may 
occasionally  be  noted  in  the  temporary  teeth — e.  g.,  secondary  dentin 
following  deep  abrasion. 

There  do  not  seem  to  be  any  observations  as  to  the  formation  of 
nodules  or  calcific  degenerations  in  the  pulps  of  temporary  teeth,  but 
there  is  no  good  reason  why  they  should  not  occur,  particularly  after 
abrasion.  The  pulp  diseases  of  the  temporary  teeth  are  usually  of 
an  acutely  destructive  nature,  which  may  account  in  some  degree 
for  the  absence  of  reports  touching  this  subject. 


CHAPTER  XIII 

DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

The  pulp  diseases  classed  under  this  heading  are  those  vascular 
disturbances  which,  in  more  advanced  stages,  tend  to  bring  about 
death  of  the  pulp.  In  the  earlier  stages,  if  maintained,  either  con- 
structive changes  or  degenerative  partial  stases  occur,  which  may 
again  lead  to  calcific  deposits.  It  will,  therefore,  be  noted  that  the 
constructive  changes  may  lead  to  the  destructive  forms  of  vascular 
disturbance  owing  to  their  presence,  while  in  turn  the  vascular 
changes  may  lead  to  constructions  if  the  degree  of  disturbance  neces- 
sary be  maintained. 

HYPEREMIA  OF  THE  PULP. 

Hyperemia  is  an  excess  of  blood  in  the  more  or  less  dilated  vessels 
of  a  part.  It  is  of  two  forms:  Active  or  arterial  and  venous  or 
passive.    These  differ  in  the  manner  of  causation  and  in  their  effects. 

In  inflammation  both  arterial  and  venous  hyperemia  occur,  together 
with  the  characteristic  emigration  of  leukocytes  and  exudate  of  coagu- 
lable  lymph,  but  neither  of  the  forms  of  hyperemia  have  these  to  any 
extent  and  therefore  they  are  not  inflammation  (see  page  34,  etc.) 

Arterial  Hyperemia  of  the  Pulp. — This  is  an  excess  of  blood  in 
the  dilated  arteries  and  capillaries  of  the  pulp,  the  pulp  functions  being 
increased  in  the  mild  continued  cases  and  disturbed  by  a  gradual 
passage  into  venous  hyperemia  in  the  more  severe  cases. 

Pathology  and  Morbid  Anatomy. — The  bloodvessels  are  under  the 
control  of  the  vasomotor  nerves  derived  from  the  sympathetic  sys- 
tem and  which  respond,  as  a  reflex,  to  irritation  of  sensory  nerves, 
through  their  relations  with  them  at  sensory  centers,  by  causing 
dilatation  of  the  arterioles.  This  dilatation  is  due  to  a  decrease  in 
the  control  of  the  caliber,  of  the  vessels  through  relaxation  of  the 
circular  muscular  fibers,  i.  e.,  the  muscular  tone  is  lost  in  proportion 
to  the  irritation  (Fig.  7) .  In  proportion  to  the  loss  of  tone,  the  vessels 
become  more  enlarged  and  tortuous  and  in  marked  cases  exhibit 
aneurysmal  enlargements  due  to  the  pressure  (Fig.  359).  It  is  prob- 
able that  a  degree  of  venous  hyperemia  is  associated  with  the  pro- 
duction of  this  state  of  the  vessels  and  as  it  becomes  more  pronounced 
(380) 


HYPEREMIA  OF  THE  PULP  381 

the  condition  of  a  fully  de^^eloped  venous  hyperemia  is  established 
(see  page  393). 

The  functions  at  first  increased  are  later  diminished  in  proportion 
to  the  A'enous  hyperemia  present.  Owing  to  the  peculiar  anatomy 
of  the  pulp  cavity  no  sharp  line  can  be  drawn. 

In  arterial  hyperemia  the  pulp  can  recover  its  tone  and  even  with 
considerable  venous  hyperemia  it  may  do  so,  but  the  recovery  is 
less  likely  especially  if  the  action  of  the  exciting  cause  cannot  be  pre- 
vented. Outside  of  these  microscopic  phenomena  nothing  remarkable 
occurs. 

Degrees  of  Arterial  Hyperemia. — It  is  plain  from  the  foregoing  and 
from  the  clinical  expressions  of  this  condition  that  every  grade  of 
arterial  hj^eremia  from  the  pure,  mild,  arterial  form  to  a  mixed 
arterial  and  venous  and  finally  to  a  profound  venous  hyperemia  may 
result  if  a  cause  be  sufficient  and  continue  its  action.  Three  grades 
may  therefore  be  established: 

1.  A  very  mild  form  -^^dthout  noticeable  symptoms  and  associated, 
as  a  rule,  with  long-continued  stimuli  and  with  constructive  effects 
as  described  under  secondary  dentin,  etc. 

2.  A  mild  form  exhibiting  increased  irritability  expressed  in  a 
reaction  to  thermal  shock  as  a  slightly  painful  response  passing  away 
promptly.  This  form  is  usually  due  to  causes  of  reasonably  acute 
nature  though  sometimes  due  to  the  later  effect  of  constructions, 
e.  (J.,  secondary  dentin  or  pulp  nodules. 

3.  A  more  severe  form,  usually  the  result  of  the  action  of  causes 
acting  more  powerfully  or  to  the  continuance  of  the  causes  producing 
the  second  grade  which  passes  into  the  third.  In  this  grade  thermal 
shock  usually  produces  more  violent  response,  shocking  a  pulp 
already  irritated  by  thermal  or  other  irritants,  and  reflex  pains,  to 
be  described  later,  are  apt  to  occur. 

Causes  and  Symptoms. — The  consideration  of  the  primary  causes  of 
arterial  h}^eremia  is  of  great  importance  as  often  their  removal  is 
the  only  treatment  necessary  for  the  recovery  of  the  pulp  and  pulp 
removal  may  be  avoided.  The  diagnosis  may  often  be  confirmed  by 
the  therapeutic  test.    They  may  be  classed  as  direct  and  indirect. 

1.  Direct  Causes. — ^A  direct  cause  is  one  acting  upon  the  pulp  by 
way  of  the  crown  of  the  tooth.  The  mode  of  action  of  the  causes 
may  be  divided  into: 

(ic)  Direct  and  immediate  action  upon  a  pulp. 

(y)  Direct  action  upon  the  fibrils  rather  than  the  pulp.  These 
being  irritated,  the  irritation  is  transferred  in  turn  to  the  odonto- 
blasts, the  sensory  nerves,  the  sensory  center,  the  sympathetic  nervous 
center,  which  via  the  vasomotor  nerves,  fm-nishes  the  motor  reflex 


382 


DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 


relaxing  the  muscular  fibers  and  causing  dilatation  of  the  arterioles, 
which  permits  the  overfulness  of  the  vessels,  establishing  arterial 
h\'peremia.  This  action  requires  a  day  or  two  to  produce  symptoms 
or  may  merely  produce  a  first-grade  hyperemia  (see  above). 

Lr.  Direct  Immediate  Causes. — These  are: 

(a)  Thermal  shock  chilling  or  heating  a  pulp  immediately  through 
a  cavity  of  decay  which  removes  the  non-conducting  covering  of  the 
pulp  (Fig.  354). 


Fig.  356 


Fig.  357 


Fig.  354. — A,  Cai-ity  or  metal  filling  approaching  pulp:  B,  hyperemic  (sometimes 
inflamed)  piilp;  C,  area  of  hyperemia  of  apical  tissue,  due  to  extension  from  the  pulp 
or  possibly  to  back  pressure  of  blood. 

Fig.  355. — A,  Area  of  non-septic  inflammation  of  apical  tissue  due  to  injury  as 
from  a  blow  or  malocclusion;  B,  hyperemia  or  mild  non-septic  inflammation  of  the 
pulp  due  to  overflow  from  the  apical  tissue. 

Fig.  356. — A,  pyorrhea  pocket;  septic  inflammation  at  C;  B,  area  of  lesser  inflam- 
mation (non-septic);  D,  hyperemia  of  pulp;  E,  normal  tissue. 

Fig.  357. — A,  ulcerated  or  necrotic  alveolar  wall  due  to  injury  and  infection;  B, 
inflammation  more  or  less  non-septic  (lesser  inflammation) ;  C,  hyperemia  of  pulp 
due  to  overflow  of  blood  at  B.  An  abscess  on  an  adjoining  root  has  the  same  pathology. 
If  extending  to  the  molar  it  infects  its  pulp  from  the  apex.     (See  pages  39,  40,  and  45.) 


(h)  A  metal  filling  placed  too  close  to  a  pulp  without  sufficient 
non-conducting  intermediate  filling  material. 

(c)  A  pulp  nodule  previously  caused  by  some  mild  irritation  may, 
through  its  presence,  excite  a  more  severe  irritation  and  hyperemia 
and  thus  be  a  cause  under  this  heading.    (See  Pulp  Xodules.) 

(d)  The  action  of  galvanism,  either  induced  by  unlike  metal  fillings 
as  a  sudden  shock,  or  by  a  galvanic  battery  as  in  cataphoresis  (or 
ionization)  or  the  action  of  electrolysis,  a  possible  occurrence  in  cata- 
phoresis.   This  vnW  be  considered  separately  (see  pages  329  and  387.) 

In  these  cases  the  cause  acts  rapidly,  the  pulp  reaction  is  prompt 
and  the  hyperemia  may  become  so  marked  that  very  slight  changes 
of  temperature  cause  painful  shocks.  The  pain,  usually  lancinating, 
may  later  not  be  felt  in  the  pulp,  but  be  reflected  to  other  localities, 
e.  g.,  the  gmn  above  or  between  the  teeth,  another  tooth,  the  ear. 


HYPEREMIA  OF  THE  PULP  383 

the  eye,  the  supraorbital  region,  the  infraorbital  region,  the  chin, 
scalp,  arm,  etc. 

As  a  rule,  when  an  upper  tooth  is  affected  the  pain  is  located  along 
the  branches  of  the  superior  maxillary  division  of  the  fifth  nerve; 
if  a  lower,  along  the  branches  of  the  inferior  maxillary  division. 
They  may  appear  in  other  branches,  however. 

It  varies  from  vague  uneasiness  to  an  acute  neuralgic  attack,  with 
tender  spots  over  the  foramina  of  emergence  of  the  nerves. 

It  is'  perfectly  possible  that  an  exposed  pulp  may  experience  these 
shocks  and  may  be  simply  hyperemic,  but  this  cannot  be  distinguished 
clinically  from  a  pulp  infection  and  inflammation  so  that  the  latter 
condition  may,  for  clinical  purposes,  be  regarded  as  pulpitis,  while 
up  to  actual  exposure  hyperemia  may  be  considered  at  least  tenta- 
tively until  the  therapeutic  test  is  applied. 

ly.  Direct  Causes  Acting  through  the  Fibrils. — The  causes  acting  in 
the  manner  described  above  (page  381)  are: 

(a)  Thermal  shocks  delivered  to  exposed  dentinal  fibrils  at  (1)  the 
cervices  of  teeth,  whether  decalcified  or  not;  (2)  upon  abraded,  eroded 
or  fractured  surfaces;  (3)  in  shallow  cavities  and  upon  metal  fillings 
placed  in  shallow  cavities. 

(6)  The  bruising  of  the  cut  ends  of  dentinal  fibrils,  through  forceful 
placement  of  gold,  amalgam  or  other  fillings  against  them.  A  mild 
reaction  is  frequent,  a  severe  one  occasionally  results. 

(c)  The  chemical  irritation  of  the  fibrils  in  cavities  or  under  crowns 
by  cements,  ca^'ity  contents,  or  the  infiltration  of  salt,  sweet  or  acid 
substances  into  contact  with  the  fibrils  exposed  in  any  location. 

(d)  Irritation  of  fibrils  by  septic  saliva  beneath  a  leaky  or  loose 
filling  or  septic  dentin  left  under  fillings,  or  septic  cement  under  a  cro^vTi. 

In  these  cases  the  pulp  becomes  hyperemic  and  usually  after 
several  days  the  tooth  responds  to  thermal  shock  as  a  mild  pain 
passing  promptly,  as  a  rule.  This  proves  the  gradual  onset  of  the 
condition. 

It  is  surprising  to  what  an  extent  the  pulp  may  protect  itself 
against  thermal  stimuli  through  the  formation  of  tubular  calcifica- 
tion and  secondary  dentin,  and  even  in  quite  deep  cavities,  this 
gradually  produced  hj^eremia  generally  passes  away  in  a  few  weeks. 
Theoretically  a  calcoglobulin  plasma  is  exuded  which  protects  the  pulp 
and  brings  about  a  toleration.     (See  page  360.) 

In  the  case  of  exposed  hypersensitive  cervices,  which  have  permitted 
a  general  pulp  hyperemia,  shown  by  the  reaction  to  cold,  applied 
anywhere  about  the  tooth,  application  of  silver  nitrate  or  other 
obtundents  to  the  sensitive  fibrils,  reduces  the  hj'peremia  if  not  com- 
plicated by  other  conditions  (pulp  nodules,  etc.). 


384        DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

In  the  cases  in  the  fourth  class  (1  y-d)  the  correction  of  the  condi- 
tion may  permit  a  comfortable  refilling,  with  antiseptic  fillings,  under 
proper  conditions,  though  this  depends  upon  the  cavity  depth  and 
the  duration  of  the  sepsis. 

As  an  example  of  a  case  of  class  (1  y-b),  a  molar  with  very  small 
distocervical  cavity  reacted  but  slightly  to  burring,  but  twice  pro- 
duced such  prompt,  sharp  and  continued  response  to  the  pressure 
of  ordinary  amalgam  insertion  as  to  compel  immediate  removal  and 
sedation  for  several  days,  after  which  a  gentle  filling  was  tolerated. 

Gold  pounded  into  shallow  cervical  cavities  has  occasionally  pro- 
duced a  hyperemic  reaction  referable  either  to  the  same  class  of 
mechanical  fibril  irritation  or  thermal  irritation. 

2.  Indirect  Causes. — The  indirect  causes  are  those  (a)  acting  through 
the  pericementum  or  (6)  through  reflex  action  from  parts  other  than 
the  affected  tooth  itself.    These  may  be  subdivided  into — 

1.  Inflammation  or  hyperemia  produced  in  the  apical  tissue  by 
trauma  or  bruise,  the  result  of  a  single  violent  blow  or  of  repeated 
blows  as  from  malletting,  malocclusion,  thread-biting,  etc.  (Fig.  355) . 

2.  Irritation  produced  by  hypercementosis,  itself  a  result  of  a 
hyperemia  of  the  pericementum. 

3.  Inflammation  or  hyperemia  of  the  apical  tissue  of  the  hyperemic 
tooth,  the  result  of  extension  of  the  hyperemic  or  non-septic  inflam- 
matory zone  (lesser  inflammation)  of  a  nearby  inflammation  into  the 
said  apical  tissue  (Fig.  357). 

The  specific  causes  of  this  third  class  of  indirect  causes  are: 

(a)  An  abscess  on  an  adjoining  tooth  (Fig.  357  will  illustrate). 

(b)  A  fairly  deep  pyorrhea  pocket  on  the  tooth  or  on  the  next 
tooth  (Fig.  356). 

(c)  An  ulcerated  alveolar  process  resulting  from  the  use  of  alveolar 
forceps,  bruising  from  a  hypercementosed  tooth  or  infection,  or  even 
the  normal  healing  inflammation  in  an  alveolus  (Fig.  357). 

(d)  An  aphthous  ulcer  upon  the  gum  over  the  tooth. 

The  mode  of  action  is  first  the  production  of  apical  hyperemia,  the 
excess  blood  from  which  flows  into  the  pulp,  causing  its  hyperemia. 

A  practical  example : 

The  writer  received  a  slight  blow  on  a  sound  lower  incisor.  On 
the  second  day  thereafter  the  tooth  was  tender  to  touch  and  responded 
to  cold.  It  was  shielded  and  after  two  or  three  days  was  normal 
to  touch  and  to  cold  applications.     This  was  a  class  2,  No.  1  case. 

It  is  possible  that  the  irritation  may  be  in  part  the  result  of  reflex 
vasomotor  disturbance,  either  beginning  with  apical  pulp  irritation 
in  the  tooth  or  at  the  area  of  original  inflammation,  thus:  Area  of 
injury,  brain  center,  reflex  to  the  tooth  pulp,    (See  2  (6),  next  page.) 


HYPEREMIA  OF  THE  PULP  385 

In  these  cases  the  primary  cause  may  be  septic  or  non-septic,  but 
in  either  case  the  pulp  hyperemia  is  considered  aseptic  unless  the 
septic  zone  comes  too  near  the  apical  foramen  in  which  case  the 
condition  becomes  one  of  pulp  infection  and  inflammation.  (See 
Pulpitis.) 

2  (6).  Reflex  Action. — An  inflamed  or  intensely  hyperemic  pulp  in 
one  tooth  may  have  its  brain  response  transferred  to  another  pulp.  In 
operation  the  sensation  from  the  first  pulp  is  carried  to  the  sensory 
center  and  either  the  pain  may  be  transferred  to  the  other  pulp 
(reflex  pain)  or  a  vasomotor  reflex  may  be  directed  into  the  second 
pulp  producing  a  h}T)eremia  (reflex  action) .  The  second  tooth  pulp 
reacts  to  cold  as  usual. 

The  cause  in  the  first  tooth,  if  suspected  or  discoverable,  should  be 
removed,  and  if  the  reaction  in  the  second  subside  a  diagnosis  of 
arterial  h\T3eremia  by  reflex  is  confirmed,  and  the  second  pulp 
requires  no  treatment.    This  reflex  to  other  pulps  is  well  known. 

A  practical  example  showing  this  result  occm-red  to  the  writer. 
A  lower  third  molar  was  extracted.  The  alveolus  healed  gradually 
with  some  local  irritation.  A  localized  scalp  tenderness  supervened 
which  passed  with  the  final  healing  of  the  tooth  socket  and  due, 
without  doubt,  to  vasomotor  disturbance  in  the  scalp  by  a  reflex. 

In  another  practical  example  an  upper  bicuspid  responded  annoy- 
ingly  to  cold.  It  had  been  well  filled  for  twenty  years.  Examina- 
tion revealed  a  large  new  amalgam  filling  on  the  buccal  of  the  third 
molar.  A  history  of  pulp  devitalization  was  given.  The  pulp  was 
found  half  dead,  the  apical  half  highly  inflamed.  Its  removal  cured 
the  reflex  h^q^eremia  in  the  bicuspid. 

In  another  case  an  almost  exposed  pulp  in  an  abraded  cuspid  pro- 
duced marked  reflex  to  a  sound  molar  which  responded  to  cold,  the 
cuspid  giving  no  pain.  The  hyperemia  in  the  molar  was  cured  by 
removal  of  the  cuspid  pulp. 

Irritation  of  branches  of  the  flfth  nerve  as  by  common  cold, 
influenza,  malaria,  sj'philis  or  tumors  may  produce  an  identical  reflex 
to  a  tooth  pulp,  causing  pulp  hyperemia  which  passes  with  the 
general  disease  if  cured.  There  is  evidence  that  some  pulps  so 
irritated  die.  Irritations  in  other  parts  as  the  uterus,  bladder,  etc., 
may  at  times,  in  like  manner,  have  the  irritation  reflected,  via  the 
brain  center,  to  a  tooth  pulp,  causing  pulp  hyperemia. 

Idiopathic  Hyperemia. — In  some  cases  with  sound  teeth  no  obvious 
cause  can  be  found,  as  a  history  of  thread-,  nail-  or  cigar-biting,  etc., 
as  evidence  of  cause  and  patients  may  deny  even  so  simple  a  true 
fact.  This  may  be  borne  in  mind.  Perhaps  the  case  is  one  due  to 
infarctions  or  pulp  nodules,  etc.  Lower  incisors  are  particularly 
25 


386        DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

prone  to  it.  The  tooth  responds  markedly  to  thermal  changes  and 
while  the  cause  may  not  be  obvious  or  obtained  by  history  or  radiog- 
raphy it  might  really  fall  under  the  previous  classifications  if  it 
could  only  be  obtained. 

Nodules  may  possibly  be  discovered  by  radiography  or  by  examin- 
ing the  pulp  after  extirpation,  rolling  it  in  the  fingers.  In  some 
marked  cases,  however,  no  cause  could  be  discovered,  though  micro- 
scopic examinations  were  not  made.  It  may  be  that  some  form  of 
septic  transference  from  some  other  focal  infection  may  account  for 
the  h}^eremia.    (See  Rosenow's  Experiments  Under  Pulp  Gangrene.) 


Hyperemia  of  the  dental  pulp,  showing  the  injection  of  the  vessels:  a,  a,  mem- 
brana  eboris,  or  layer  of  odontoblasts;  b,  b,  b,  b,  vessel  distended  with  blood:  c,  c,  c,  c, 
points  from  which  the  blood  has  fallen  in  handling  the  section.     (Black.) 

Hartzell  and  Henrici^  are  of  the  opinion  that  bacteria  may  enter 
the  pulp  from  the  gum  margin  by  way  of  the  pericemental  channels 
or  be  transferred  from  abscessed  teeth  several  teeth  away  as  they 
claim  to  have  found  them  on  examination.  Regardless  of  cause  the 
pulp  must  be  removed. 

There  are  some*  individuals  nearh"  all  of  whose  sound  teeth  are 


1  Journal  of  the  National  Dental  Assn.,  May,  1917,  p.  493. 


HYPEREMIA  OF  THE  PULP 


387 


sensitive  to  thermal  changes  sometimes  for  Kfe.  Whether  this  is  due 
to  some  abnormal  sensitivity  of  pulp  tissue  or  to  the  thinness  of  the 
enamel  and  dentin  overlying  it  is  not  clear. 

Pulp  Irritation  from  Electric  Action. — It  is  of  quite  common  occur- 
rence that  galvanic  electricity  causes  pulp  irritation.  The  cataphoric 
current  too  long  continued  may  induce  a  hyperirritability  of  the 
pulp  amounting  in  some  cases  to  evidence  of  hyperemia,  which 
may  subside  under  proper  treatment  or  eventuate  in  pulp  death  from 
venous  hyperemia.  The  occasional  connection  of  a  newly  placed  or 
bright  amalgam  filling  with  a  gold  filling,  bridge,  plate,  or  clasp, 
through  the  medium  of  saliva  or  food  (which  amounts  practically 
to  the  same  thing),  will,  at  times,  produce  painful  galvanic  shocks  in 
a  vital  tooth.     Dr.  Franz  Trauner^  has  reported  that  such  pain  has 

Fig.  359 


Dilated  bloodvessels  from  the  dental  pulp  in  hyperemia,  from  tooth  extracted  during  a 
paroxysm  of  intense  pain.  (Black.) 


been  felt  in  devitalized  teeth.  This  is  outside  of  the  editor's  experi- 
ence, and  should  not  occur  in  totally  devitalized  teeth,  as  the  electric 
current  is  a  test  for  pulp  ^itality.  I  have  later  noted  a  case  of  shock 
in  a  vital  left  upper  bicuspid  filled  with  amalgam  opposed  by  a  dead 
left  lower  bicuspid  with  gold  crown  after  insertion  of  amalgam  in  a 
right  lower  tooth.  It  occurred  only  when  the  mouth  was  closed  and 
was  felt  as  though  in  the  lower  left  tooth.  Dr.  Paul  ^Manning- 
recounts  a  case  in  w^hich  gold  placed  entirely  over  a  substratum  of 
old  amalgam  filling  produced  intolerable  pain  which  was  relieved  by 
Irilling  through  the  gold  to  the  amalgam  and  filling  the  drill  hole 
with  amalgam,  thus  bringing  both  into  contact  with  the  oral  fluids. 

1  See  Dental  Cosmos,  1903. 

2  Pental  Cosmos,  1918  p.  29, 


388  DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

The  mouth  mirror,  or  a  fork  or  pm,  or  a  brass  depressor  touched  to 
a  new  amalgam  filHng,  may  also  produce  the  pain,  but  a  nickelled  steel 
instrument  usually  does  not,  but  may  connect  mirror  and  filling. 

Painful  shock  is  sometimes  produced  by  the  animal  electricity 
discharged  from  the  operator  during  dry,  cold  weather.  It  usually 
occurs  when  the  finger  is  placed  upon  a  metal  filling,  or  the  plugger 
point  is  returned  to  a  metal  filling.  Touching  the  metal  part  of  the 
chair  before  approaching  the  patient  will  obviate  this  disagreeable 
contact. 

Treatment. — With  cataphoresis,  the  mischief  being  accomplished, 
the  case  must  be  treated  as  other  arterial  hyperemias. 

In  the  case  of  shocks  from  the  presence  of  the  two  metals  it  may 
be  ignored  if  slight  and  the  filling  new,  as  it  will  probably  soon  pass 
away.  If  the  fillings  be  in  adjoining  teeth,  they  should  be  contoured 
so  as  to  touch  persistently  if  possible.  If  in  the  same  tooth,  the 
fillings  should  be  connected  by  either  amalgam  or  gold.  A  well-set 
and  brightly  polished  amalgam  filling  may  be  tarnished  if  necessary 
by  touching  it  with  a  1  per  cent,  solution  of  silver  nitrate;  or,  if 
good  color  be  a  necessity,  the  pulp  of  the  tooth  may  be  well  in- 
sulated by  means  of  a  gutta-percha  substratum,  or  the  pulp  may 
be  devitalized. 

Associated  Hyperemia  of  Pericementum. — In  all  pronounced  pulp 
hyperemias  and  inflammations  (which  latter  are  hyperemic  conditions 
also)  some  of  the  excess  blood  may  find  its  way  into  the  apical  tissue 
and  cause  apical  hyperemia  with  symptoms  of  tenderness  to  tapping 
upon  the  tooth  or  even  to  touch  (Fig.  354). 

In  a  rare  case  of  a  lower  cuspid  with  small  labial  cavity  filled  with 
a  silicate  cement,  a  class  ly-b,  direct  cause,  produced  arterial  hyperemia 
and  a  persistent  mild  tenderness  to  touch  without  a  corresponding 
reaction  to  cold.  It  was  relieved  by  refilling  with  oxid  of  zinc  and 
eugenol  cement  for  a  few  weeks.  Later,  after  varnishing  the  cavity 
floor,  the  silicate  was  replaced  without  further  irritation. 

Diagnosis. — When  a  tooth  pulp  responds  to  thermal  stimuli,  espe- 
cially to  moderate  heat  or  cold,  hyperemia  or  inflammation  (also 
h\'peremic)  is  inferred.  Assuming  the  response  to  be  in  a  tooth 
without  pulp  exposure,  and  not  too  long  continued,  a  direct  cause  in  a 
cavity,  recent  metal  filling,  etc.,  hypersensitivity  at  cervices,  sepsis 
under  filling,  etc.,  as  shown  above,  is  first  sought,  and  if  found,  cor- 
rected, as  for  example,  by  sedatives  on  cotton  in  a  cavity,  sedative 
filling,  etc.,  permanent  filling,  if  indicated,  silver  nitrate  to  hyper- 
sensitive necks,  etc.  Direct  causes  not  being  discovered,  indirect 
causes  or  reflexes  are  sought  and  removed  or  treated. 

Failing  an  apparent  acute  cause,  fifled  teeth  are  tested  to  determine 


HYPEREMIA  OF  THE  PULP  389 

the  h^'peremic  pulp  and  the  fiUing  removed  to  discover,  if  possible, 
any  condition  causing  inflammation  with  which  arterial  hyperemia  is 
always  associated  (see  Pulpitis,  etc.),  or  possibly  septic  dentin  may 
be  present  under  the  filling  as  a  cause  of  IniDeremia. 

Whether  as  a  cause  of  h^^Deremia  or  inflammation  is  judged  by 
the  degree  of  approach  to  the  pulp  and  the  response  to  treatment. 

In  testing  a  reflex  to  a  pulp  or  to  some  other  part,  the  suspected 
tooth  is  subjected  to  drop  after  drop  of  cool  or  cold  water  as  indicated 
in  the  endeavor  to  cause  an  acute  paroxysmal  response. 

In  testing  to  determine  which  of  several  teeth  contains  the  hyper- 
emic  pulp  two  methods  are  employed : 

1.  The  head  is  thrown  well  back  so  that  the  water  runs  into  the 
throat.  Then  drop  by  drop  cold  water  is  thrown  on  the  most  posterior 
tooth.  Time  is  allowed  for  eft'ect.  None  resiflting,  it  is  then  dropped 
upon  the  tooth  next  anterior,  and  so  on,  until  a  sensitive  tooth  is 
found. 

2.  A  square  or  full  piece  of  rubber  dam  with  a  single  hole  is  passed 
over  one  tooth  and  the  cold-water  test  applied.  Heat  in  the  form  of 
hot  gutta-percha,  hot  air,  etc.,  may  be  used.  If  two  teeth  only  are 
in  question  and  the  dammed  one  excluded  the  dam  is  then  folded 
over  the  excluded  tooth  and  the  water  thrown  on  the  other.  If 
several  teeth  are  under  suspicion  each  is  dammed  in  turn  and  tested. 
In  some  cases  a  piece  of  lubricated  dam  is  run  between  the  teeth 
and  may  be  folded  over  one  or  the  other. 

As  stated,  the  location  of  a  hyperemic  pulp  does  not  alone  warrant 
its  removal.    The  appropriate  cause  must  first  be  considered. 

Idiopathic  cases  are  different,  which  see. 

The  electric  diagnostic  lamp  shows  the  pulp  engorgement  in  some 
of  the  advanced  cases. 

Radiography  is  useful  in  occult  cases  as  a  means  of  diagnosing 
pulp  canal  constriction  by  secondary  dentin  or  pulp  nodules. 

In  advanced  cases  responding  markedly  to  thermal  changes,  a 
history  of  a  deep  fiUing,  pressure  pain  at  the  time  of  filling,  etc.,  is 
evidence  to  be  considered  in  making  up  a  diagnosis.  In  such  cases 
the  hyperemia  is  usually  progressive  toward  the  venous  variety  and 
frequently  not  the  slightest  thermal  change  is  tolerable. 

Prognosis. — The  prognosis  is  good  for  all  moderate  cases  if  the 
action  of  the  causes  can  be  prevented,  as  pulp  may  recover  its  tone. 
(See  page  380.)  In  flat  abrasions  with  the  pulp  nearly  exposed,  it  is 
unfavorable.  In  fractures  not  exposing  the  pulp,  caps  ma}'  be  used 
to  advantage,  especially  in  children's  teeth.  Pure  gold  cro^-ns  may 
be  used  until  such  time  as  the  pulp  canals  are  complete,  though 
pulp  removal  may  or  may  not  be  required  for  the  final  restorations. 


390         DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

In  pulp  capping  cases  the  prognosis  is  not  good,  but  unless  the 
reaction  is  severe  and  if  it  grows  less  gradually  under  counter- 
irritation,  success  may  be  hoped  for. 

Great  reactions  to  thermal  shock  in  deep  cavities  offer  a  rather 
unfavorable  prognosis,  but  an  effort  to  save  through  sedation  may 
be  made  unless  there  be  no  room  for  non-conductors. 

Treatment.^ — Open  cavity  cases  require  the  exclusion  of  the  causes, 
usually  sepsis  and  other  chemical  irritants  and  thermal  stimuli. 
In  some  cases  the  pulp  must  be  sedated  to  allow  the  vessels  to  recover 
their  tone.  Filling  with  these  points  in  mind,  i.  e.,  asepsis,  non- 
conduction  and  permanence  is  indicated.  (See  Almost  Exposed 
Pulp.) 

In  the  most  doubtful  cases,  with  deep  cavity  and  great  irritation, 
sedatives  applied  on  cotton  for  a  few  days  are  indicated.  The  cavity 
is  excavated  as  far  as  possible  and  the  application  renewed,  at  least 
daily,  either  by  the  operator  or  patient  until  sedation  is  accomplished. 

In  somewhat  less  doubtful  cases,  oxyeugenol  plus  a  trifle  of  th}'- 
mol  may  be  used  as  a  temporary  filling  to  be  later  entirely  or 
partially  removed,  or  Jodoformagen  covered  by  oxyeugenol  may  be 
used.  As  a  preferable  alternative  Jodoformagen  may  be  placed  in 
the  pulpal  wall  of  the  cavity  and  a  soft,  quick-setting  cement  plus 
thymol  flowed  over  it  as  a  cavity  lining,  over  this,  when  set,  a  gutta- 
percha base  plate  is  to  be  placed  to  flll  the  cavity  temporarily. 

In  moderate  cases  the  cavity  may  be  touched  with  oil  of  cajuput, 
etc.,  and  gutta-percha  introduced  as  a  temporary  filling. 

In  simpler  cases  a  permanent  combination  filling  of  cement  plus 
thymol  and  amalgam  (if  indicated)  may  be  used,  or  the  cement  lining 
may  be  used  with  gold  in  view.  The  cement  plus  thjinol  may  be 
placed  to  be  partly  cut  out  later,  or  a  gutta-percha  intermediate  may 
be  covered  with  cement  and  amalgam  (or  later  gold  may  be  used 
instead) . 

The  indications  vary  with  the  cavity  depth  and  the  degree  of 
irritation,  and  in  some  cases  may  require  temporary  filling  with 
gutta-percha  or  cement  for  some  time. 

In  all  cases  of  very  deep  cavities  non-conductors  must  be  placed 
as  a  prophylactic  against  thermal  shock.  This  may  consist  of  var- 
nish, or  a  layer  of  gutta-percha  base  plate.  In  general  the  writer 
prefers  the  Jodoformagen  and  thymolized  cement  above  mentioned 
as  fulfilling  immediate  and  subsequent  requirements. 

When  hypersensitive  cervices  are  the  cause  of  the  pulp  irritation 
several  applications  of  silver  nitrate,  at  intervals  of  a  few  days,  will 
usually  reduce  the  hyperemia  in  a  few  weeks.  The  fibrils  are  super- 
ficially devitalized  and  cannot  transmit  the  irritation  and  the  pulp 


HYPEREMIA  OF  THE  PULP  391 

recovers  its  tone  gradually.  In  case  nodules  or  pulp  cavity  constric- 
tion has  occurred,  the  irritability  cannot  be  reduced  in  this  manner. 
In  case  of  septic  dentin  this  is  to  be  removed  and  antiseptic  substrata 
of  filling  employed,  as  above. 

In  the  indirect  cases  the  cause  is  removed  and  the  tooth  in  question 
requires  no  treatment,  except  perhaps  counterirritation,  which  is  a 
means  toward  the  reduction  of  any  pulp  h\'])eremia.  In  some  cases  of 
trauma  guards  must  be  applied  to  adjoining  teeth.  (See  Non-septic 
Pericementitis.)  As  stated  above,  certain  mild,  hyperemic  reactions 
after  filling  require  no  treatment  as  a  rule. 

Sedatives. — Oil  of  cloves,  eugenol,  eugenol  and  phenol  equal  parts, 
phenol  camphor  (equal  parts  phenol  and  camphor),  thymophen 
(phenol  and  thymol,  p.  seq.),  menthophenol  (menthol  3  phenol  1), 
a  saturated  solution  of  thymol  in  alcohol,  a  saturated  solution  of 
menthol  in  chloroform. 

Solutions  of  cocain  or  novocain:  Dental  one,  Phenandyne  and  the 
fluid  of  "  Jodoformagen"  are  valuable  proprietary  agents.  To  any 
oil,  etc.,  not  containing  them,  menthol,  thymol,  cocain  or  novocain 
may  be  added. 

OxyeugenoP  is  a  sedative  temporary  filling  as  is  Fletcher's  car- 
bolized  resin  plus  zinc  oxid.     (See  page  335.) 

Counterirritation. — It  not  infrequently  happens  that  it  becomes 
necessary  to  assist  the  pulp  arteries  to  recover  their  tone  by  means 
of  counterirritants  applied  to  the  gum  over  the  apex  of  the  root. 
This  is  especially  true  in  cases  of  pulp  capping.  Dental  tincture  of 
iodin  (iodin,  5iij;  alcohol,  §j;  dissolve  by  succussion;^)  or  potassium 
iodid,  sat.  sol.,  and  zinc  sulphate,  sat.  sol.,  p.  seq.,  with  iodin  crystals 
to  complete  saturation^  is  to  be  applied  in  spots  to  the  gums,  or  a 
mixture  of  equal  parts  of  tincture  of  iodin  and  tinctm-e  of  aconite  may 
be  painted  upon  the  gum.  A  mixture  made  of  two  parts  of  tincture  of 
aconite  and  one  part  of  chloroform  is  recommended  by  Jack,^  to  be 
applied  to  the  cleansed  and  dried  mucous  membrane  by  means  of  a 
pad  of  cottonoid,  one-half  inch  wide  by  three-quarters  of  an  inch 
long.  It  should  be  held  in  place  by  the  finger  for  fifteen  seconds. 
Tincture  of  aconite  upon  cotton,  placed  in  the  rubber  cup-applicator 
of  a  cataphoric  apparatus  and  held  against  the  gum  for  a  half  minute 
while  the  current  of  a  few  cells  is  active,  will  produce  a  circum- 
scribed area  of  irritation  which  may  later  lose  its  epidermis.     This 

1  Oxyeugenol  is  composed  of  Hubbuck's  zinc  oxide  and  eugenol  in  a  stiff  mixture. 
It  hardens  in  the  saliva.  The  material  was  introduced  by  Dr.  S.  B.  Luckie  and  the 
UTiter  uses  the  name  as  convenient. 

2  Flagg.  s  Northrop. 
4  American  Text-book  of  Operative  Dentistry. 


892         DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

amount  of  irritation  is  valuable.  A  capsicum  plaster  may  be  used. 
For  an}'  case  of  obdurate  pain  systemic  sedation  or  derivation  may 
be  employed.    (See  page  405.) 

The  test  of  success  of  remedial  measures  is  the  gradual  reduction 
of  response  to  slight  variations  in  temperature — i.  e.,  the  pulp  grad- 
ually bears  higher  and  lower  temperatures  until,  approximately, 
a  normal  tolerance  is  established. 

As  shown  by  Jack,  this  varies  for  hot  applications  from  118°  F.  to 
152°  F.,  and  for  cold  ones  from  74°  F.  to  32°  F. 

In  order  to  determine  the  rate  of  tolerance  normal  to  the  individual, 
he  suggests  that  sound  lower  incisors  be  isolated  by  the  rubber  dam 
and  tested  by  throwing  upon  them  first  water  at  a  temperature  of 
80°  F.  The  temperature  of  the  water  is  then  gradually  lowered  or 
raised  until  slight  pain  is  produced  by  the  test.  The  point  registered 
by  the  thermometer  will  be  the  normal  limit  of  thermal  tolerance  for 
the  particular  test. 

The  data  gained  are  useful  in  determining  the  progress  of  a  case 
of  hyperemia. 

A  lack  of  success  in  the  reduction  of  the  arterial  hyperemia  is 
evidence  that  the  more  severe  condition  of  venous  hyperemia  has 
supervened,  or  perhaps  an  infection  has  caused  a  true  inflammation. 

When,  after  fair  trial  of  conservative  treatment,  the  pulp  is  per- 
sistently irritable,  it  should  be  removed. 

In  the  devitalization  of  hyperemic  pulps  there  is  often  painful 
reaction  to  any  of  the  means  employed.  Some  of  these  pulps  resist 
cocain  pressure  in  any  form  even  after  sedation;  some  yield  after 
sedation.  Sedation  or  depletion  should  precede  arsenical  applica- 
tions, and  if  at  any  time  arsenic  produce  a  painful  hyperemia  or 
aggravate  one  previously  existing,  it  must  be  removed  and  sedatives 
used  before  its  renewal,  or  it  may  be  applied  at  another  portion  of 
the  tooth  while  sedatives  are  kept  against  the  pulp.  Other  methods 
of  removal  are  considered  in  the  chapter  on  Pulp  Removal. 

Venous  Hyperemia  of  the  Pulp. — Definition. — By  venous  or  passive 
hyperemia  of  the  pulp  is  meant  a  condition  of  the  pulp  in  which 
the  return  of  the  blood  in  the  pulp  to  the  heart  is  mechanically 
prevented. 

Causes,  Pathology,  and  Morbid  Anatomy. — But  two  causes  seem 
competent  to  produce  such  a  venous  hyperemia.  These  are:  (1)  A 
preexistent  arterial  hyperemia;  (2)  thrombosis  of  vessels  at  the 
apex  of  the  pulp  canal.  The  venous  hyperemia  which  is  the  second 
stage  of  inflammation  is  to  be  remembered,  but  excluded  from  present 
consideration.  It  would  act  by  first  producing  a  zone  of  arterial 
hyperemia  which  then  would  produce  venous  hyperemia. 


HYPEREMIA   OF  THE  PULP  393 

In  arterial  hyperemia  the  excess  of  blood  is  contained  in  enlarged 
capillaries  and  arterial  trunks.  The  enlarged  main  trunks  or  trunk 
at  the  apex  of  the  pulp  must  compress  the  veins,  as  the  apex  of  the 
canal  is  unyielding.  In  proportion  to  the  severity  of  the  arterial 
hyperemia,  therefore,  are  the  emergent  veins  unable  to  remove  the 
blood  collected  in  the  capillaries  and  venules,  which  gradually  enlarge 
into  varicosities  in  consequence  (Fig.  359).  Black^  has  termed  this 
condition  infardion  an  evident  misnomer  as  infarction  is  due  to  a 
stoppage  of  an  end  artery  while  venous  hj-peremia  is  due  to  a  stop- 
page of  the  vein.     (See  page  27.) 

It  has  been  shown  by  Hopewell-Smith-  that  thrombosis  of  the 
small  veins  and  capillaries  throughout  the  pulp  may  result  in  rupture 
of  the  arteries,  and  hemorrhagic  extravasations  occur— either  single 
or  multiple.  These  he  terms  hemorrhagic  infarcts,  although  the 
description  given  more  accurately  denotes  a  minute  venous  hyper- 
emia.   (See  Fibroid  Degeneration  of  the  Pulp.) 

Black  has  shown  that  the  diapedesis  of  red  corpuscles,  which  is  a 
characteristic  result  of  engorgement  of  the  veins  in  venous  hyper- 
emia, occurs  in  the  pulp.  Edema,  which  usually  accompanies  venous 
hyperemia  in  other  situations,  cannot  well  occur  in  the  pulp  because 
of  its  unyielding  surroundings  (Fig.  360). 

It  is  possible,  however,  that  fluid  may  exude  into  the  perivascular 
spaces,  compressing  the  cellular  elements.  Black  has  shown  that 
deposits  of  lymph  may  thus  occur  in  pulpitis.  Dewey  and  Noyes^ 
after  carefully  conducted  experiments  upon  pulps  of  dogs  and  rabbits, 
are  of  the  opinion  that  lymphatics  exist  in  the  pulp  so  that  some  of  the 
fluid  may  be  thus  taken  up  in  partial  continued  cases.  These  return 
vessels  would,  however,  be  subject  to  compression  like  the  veins  in  the 
pulp  canal.  The  intense  congestion  and  distention  of  the  vessel 
walls  permit  a  free  diapedesis  of  red  corpuscles  into  the  pulp  tissue. 
Disintegration  of  the  red  corpuscles  may  occur  and  the  hemoglobin 
of  the  corpuscles  may  be  diffused  through  the  dentin,  giving  it  a 
pink  discoloration  technically  known  as  "suffusion.'"  The  infiltrated 
dentin  may  then  become  progressively  discolored  through  the 
characteristic  changes  of  color  noted  in  connection  wdth  gradually 
decomposing  hemoglobin — becoming  purplish,  dark  blue,  and  finally 
blue  black.  The  color  may  pass  into  the  yellow  or  brown  coloration 
(see  Tomes'  case).  Cases  have  occurred  of  coronal  suffusion  in  which 
the  pulp  vitality  has  persisted  for  months.  In  some  cases  the  bulbar 
portion  alone  may  be  dead.  Thus  partial  gangrene  and  the  general 
darkening  of  the  tooth  may  be  present  even  in  a  single-rooted  tooth 

1  Special  Dental  Pathology,  1915,  p.  257. 

2  Dental  Cosmos,  1907.  ^  ibid.,  April,  1917, 


394        DESTRUCTIVE  DISEASES  OE  THE  DENTAL  PULP 

with  the  pulp  partl.y  aHve.  This  is  proof  that  collateral  circulation 
exists  in  the  pulp.  In  cases  of  suffusion  even  all  the  roots  of  a  molar 
may  be  suffused,  and  pericementitis,  associated  with  such  a  hyperemia 
seems  particularly  intractable.  The  vasomotor  paralysis  is  extreme. 
Tomes^  records  a  case  of  a  blow  upon  four  upper  incisors,  which 
became  loose  and  painful.  A  few  days  afterward  reddish  spots 
appeared  upon  the  labial  surface,  which  later  became  dark  blue. 
These  disappeared  except  for  a  slightly  yellowish  tint.  Four  years 
later  the  pulps  were  found  vital  and  healthy.  This  rare  case  is  con- 
firmative of  the  previous  statements. 

Fig.  360 


Section  of  hyperemic  pulp,  showing  aneurysmal  dilatation  of  the  vessels,  extra- 
vasations of  blood,  and  red  blood  disks  escaped  apparently  by  diapedesis:  a,  a.  dilated 
vessels;  b,  b,  b,  extravasated  blood.  Besides  this,  red  blood  disks  are  plentifully 
distributed  everywhere  in  the  neighborhood  of  the  veins.  The  tooth  was  extracted 
during  a  paroxysm  of  pain.     (Black.) 

If  a  tooth  receive  a  blow  of  sufficient  severity,  its  pulp  may  die 
without  much  evidence  of  pulp  pain.  On  the  other  hand,  if  the 
blow  be  less  severe,  it  may  give  evidence  of  an  arterial  hyperemia, 
gradually  increasing  in  severity. 


Manual  of  Dental  Anatomy. 


HYPEREMIA  OF  THE  PULP  395 

In  the  former  case  it  is  probable  that  the  bruising  of  the  apical 
tissue  produces  a  condition  of  thrombosis  at  the  apex  which  involves 
the  pulp  by  shutting  off  both  its  arteries  and  veins.  A  stagnation 
results,  and  death  from  lack  of  nutrition  occurs.  This  is  also  termed 
"jugulation." 

In  the  latter  case  the  thrombosis  has  not  occurred,  but  an  arterial 
hyperemia  is  set  up  by  the  overflow  of  blood  from  the  apical  tissue 
into  the  pulp,  and  goes  on  to  venous  hyperemia. 

It  is  quite  probable  that  rapid  death  of  the  pulp  in  pulpitis  is  due 
to  the  associated  venous  hyperemia. 

Kirk^  mentioned  an  interesting  case  of  venous  hyperemia  wuth 
intense  suffusion  of  all  the  teeth  as  the  result  of  hanging.  In  such  a 
case  there  was  arterial  blood  supplied  to  the  teeth,  but  the  venous 
flow  was  checked.    This  is  said  to  be  usual. 

Symptoms. — This  disease  is  inferred  w^hen  the  conditions  and 
history  indicate  hj^eremia  rather  than  inflammation,  and  w^hen 
the  paroxysms  of  pain  are  continuous,  instead  of  temporary — that 
is,  when  the  pain,  instead  of  temporarily  subsiding,  maintains  a 
constant  intensity  for  hours  and  does  not  respond  promptly  to 
sedative  therapeusis,  and  is  accompanied  by  a  sense  of  fulness 
rather  than  sharp  agony.  The  case  from  which  Fig.  360  was  taken 
had  been  the  seat  of  intense  paroxysmal  pain  for  some  hours.  Upon 
close  approach  to  such  a  pulp,  blueness  of  the  horn  instead  of 
pinkness  may  sometimes  be  seen.  It  may  be  noted  with  light 
transmitted  by  an  electric  mouth  lamp. 

Prognosis. — Perfect  recovery  from  this  condition  is  extremely 
doubtful,  so  that  if  the  pulp  be  not  intentionally  devitalized  and 
removed,  it  will  undergo  degenerative  changes.  The  fact  that  pulps 
have  remained  alive  for  years,  after  having  been  the  seat  of  marked 
congestion,  scarcely  warrants  the  attempt  to  save  so  seriously 
crippled  an  organ. 

Treatment. — The  prognosis  being  doubtful,  the  pulp  should  be 
obtunded  and  devitalized.  If  the  pulp  pain  does  not  yield  to  seda- 
tives, it  should  be  gently  exposed  if  the  excavation  does  not  accom- 
plish its  exposure.  An  antiseptic  is  to  be  applied,  and  by  means 
of  a  very  sharp  puncture  probe  the  pulp  is  to  be  delicately  punctured. 
A  free  flow  of  blood  follows,  which  relieves  the  vascular  engorgement. 
When  this  is  accomplished  the  cavity  is  to  be  syringed  out  with 
warm  water,  and  a  pellet  of  cotton  containing  a  saturated  solution 
of  menthol  in  chloroform  may  be  sealed  in  the  cavity,  or  simply 
retained  by  means  of  a  second  pellet  of  cotton  saturated  with  in- 

1  Private  communication. 


396         DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

spissated  tincture  of  benzoin  or  chloro-percha.  Chloroform  alone 
for  a  few  minutes  to  be  followed  by  an  application  of  eugenol  has  been 
suggested  by  Shalit.  After  twenty-four  hours  an  arsenical  application 
may  be  made  for  the  purpose  of  pulp  devitalization,  or  the  pulp  may 
be  removed  by  other  means  if  tolerated.  If  desired,  the  bulb  of  the 
pulp  may  be  taken  out  under  general  anesthesia,  or  the  whole  pulp 
under  mucous  or  conductive  anesthesia  or,  possibly,  under  pressure 
anesthesia,  though  intense  hyperemia  counteracts,  as  a  rule,  (See 
page  312.) 

The  extreme  paralysis  of  the  vessel  walls  is  occasionally  shown  by 
persistent  hemorrhage  after  depletion,  and  which  resists  ordinary 
effort  at  limitation.  In  some  cases  the  intense  pain  may  continue 
as  well.  The  application  to  the  pulp  of  a  mixture  of  powdered 
thymol  and  dried  alum,  equal  parts,  taken  up  on  a  pellet  of  cotton 
moistened  with  a  saturated  solution  of  thymol  in  alcohol,  or  other 
sedative,  has  proved  useful  in  some  cases.  A  general  anodyne  may 
be  required  for  relief  of  the  pain. 

INFLAMMATION   OF   THE   PULP  (PULPITIS). 

Definition. — Pulpitis  is  the  occurrence  of  the  phenomena  of  inflam- 
mation within  the  pulp  tissue.  The  characteristic  emigration  of 
leukocytes  from  the  bloodvessel  into  the  perivascular  tissues  must 
have  occurred.     (See  page  37.) 

Causes. — The  causes  of  pulpitis  may  be  classed  under  three  headings: 

1 .  Mechanical  or  physical  causes.  The  pressure  of  a  filling  upon  a 
thin  lamina  of  dentin  or  upon  an  exposed  pulp,  or  even  extending 
into  it.  The  pressure  of  a  hemorrhagic  extravasation  into  the  pulp 
tissue,  the  presence  of  a  pulp  nodule,  or  pulp  cavity  constriction. 
The  torsion  of  a  pulp  in  orthodontia^  or  as  a  result  of  trauma  as  from 
biting  hard  substances,  rapid  wedging  and  mastication  upon  teeth 
loosened  by  pyorrhea,  the  pressure  of  an  impacted  tooth  upon  a 
pulp  at  the  apical  region  or  at  a  point  of  resorption  are  all  possible 
causes  some  of  which  might  also  produce  arterial  hyperemia.  In 
cavity  cases  the  force  of  mastication  or  suction  by  the  tongue  are 
causes  while  sepsis  may  be  an  added  cause. 

2.  Chemical  causes,  as  oxychlorid  of  zinc,  chlorid  of  zinc,  formalde- 
hyde or  other  irritant  or  escharotic  used  upon  the  pulp.  If  any  dead 
tissue  is  formed  the  effort  at  exfoliation  causes  an  inflammatory 

1  Buckley,  through  a  circular  letter  to  orthodontists,  obtained  opinions  that  the 
upper  centrals  and  laterals  are  most  liable  owing  to  the  frequency  of  displacement, 
character  of  movement,  prominence  of  location,  and  the  curve  of  lateral  roots.  Items 
of  Interest,  December,  1910 


INFLAMMATION  OF  THE  PULP  397 

reaction  on  the  part  of  the  pulp  with  intent  of  exfoHation  or  absorp- 
tion. 

3.  Parasitic  or  infective  causes  which  cause  the  phenomena  of 
infective  inflammation. 

Bacteria  may  gain  access  to  a  pulp  in  one  of  five  recognized  ways: 

(a)  Via  the  dentinal  tubules,  the  fibrils  first  being  devitalized. 
Septic  soft  dentin  under  a  filling  is  a  cause  of  this,  as  is  also  a  sound 
but  infected  cavity  floor.  Secondary  dentin  also  may  admit  infection, 
via  its  spaces.  Goadby  has  shown  that  Streptococcus  brevis  and 
Bacillus  necrodentalis  may  so  pass  and  lately  it  has  been  apparently 
proved  that  apparently  hard  dentin  in  "vdtal  teeth  may  contain 
bacteria. 

(6)  Via  an  exposed  pulp  horn. 

(c)  Via  a  pyorrhea  pocket  deep  enough  to  admit  bacteria  to  an 
apical  space.  In  single-rooted  teeth  this  may  cause  rapid  death. 
In  multirooted  teeth  a  partial  pulpitis  may  occur.  The  pulp  infec- 
tion occurs  from  the  apex  toward  the  crown.  Hartzell,  observing  150 
cases  of  sound  teeth  with  dead  pulp,  suggests  (tentatively  only)  that 
as  bacteria  were  found  in  some  of  them  the  primary  cause  of  death  may 
have  been  infection  entering  at  the  gingival  margin  travelling  through 
the  pericemental  vessels  to  the  pulp.  He^  also  has  observed  strepto- 
cocci in  apical  regions  of  teeth,  several  teeth  distant  from  an  abscessed 
tooth. 

{d)  Through  the  extension  of  an  abscess  upon  an  adjoining  tooth, 
thus  causing  an  apical  infection  of  the  pulp  in  question  and  if,  of 
rapid  extension  will  destroy  the  apical  tissue  and  cause  pulp  death. 
This  second  pulp  may  then  act  as  a  continuing  cause  of  apical  abscess. 

{e)  Via  the  circulation  in  which  the  bacteria  of  influenza  or  from 
various  foci  of  infection  may  locate  in  a  tooth  pulp.  Rosenow^  experi- 
mented on  animals,  injecting  intravenously  streptococci:  (1)  from 
infected  pulp  canals;  (2)  from  infected  apical  tissue;  (3)  from  infected 
tonsils  and  found  it  experimentally  possible  that  focal  infection 
becoming  hematogenous  could  cause  infection  of  a  tooth  pulp  which 
may  explain  certain  idiopathic  hyperemias  and  inflammations  in 
sound  teeth  or  those  not  offering  local  explanation.  Cases  of  pulp 
death  apparently  following  influenza  have  been  reported  and  might 
be  due  to  such  an  infection  from  B.  influenza  existing  in  the  blood. 
As  it  can  produce  antral  empyemia  de  novo  there  is  no  reason  why  such 
observations  should  not  have  credence,  if  accurate  and  not  merely 
deduced  from  the  presence  of  devitalized  teeth  after  influenza 
without  knowledge  of  their  previous  vital  character. 

1  Hartzell  and  Henrici:    Journal  of  National  Dental  Assn.,  May,  1917,  p.  493. 
-  Journal  of  National  Dental  Assn.,  February,  1918, 


398 


DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 


Pulpitis  is  classified,  according  to  its  extent,  into  partial  and  com- 
plete; according  to  its  duration,  into  acute  and  chronic;  according 
to  its  infective  character,  into  purulent  and  non-purulent;  and, 
again,  according  to  the  character  of  the  degeneration  which  follows 
upon  the  infiammatory  process.  While  pathologically  these  con- 
ditions may  be  clearly  differentiated  from  one  another,  they  may  be 
reduced  to  more  compact  groupings  according  to  their  clinical  sig- 
nificance. For  example,  acute  pulpitis  is  frequently  infective,  partial, 
and  purulent;  chronic  pulpitis  is  frequently  non-infective,  extensive, 
non-purulent,  and  followed  by  secondary  degenerations.  It  is, 
however,  often  purulent,  and,  of  course,  infective. 
•  For  the  sake  of  convenience,  pulpitis  will  receive  a  clinical  division 
into  acute  and  chronic. 

Fig.  361 


Inflammation  of  dental  pulp;   a,  a,  normal  cells;  b,  b,  b,  b,  inflammatory  elements: 
c,  cells  in  process  of  division  (yV  inch.)     (Black.) 

Acute  Pulpitis. — By  acute  pulpitis  is  meant  that  form  of  inflam- 
mation of  the  pulp  which  runs  an  active  and  more  or  less  violent 
course  toward  pulp  death,  and  has  associated  with  it,  as  a  rule, 
acute  paroxysms  of  pain. 

Morbid  Anatomy  and  Pathology. — In  determining  the  existence  of 
pulpitis,  no  matter  what  the  symptoms  which  have  presented  or  the 
condition  as  to  exposure,  etc.,  the  microscopic  examination  of  sections 
of  the  affected  organ  constitutes  the  only  decisive  test;  if  the  changes 
characteristic  of  inflammation  be  absent,  no  matter  what  the  symp- 
toms, pulpitis  did  not  exist.  The  essential  feature  of  the  process  is 
emigration  of  the  white  blood  corpuscles  from  the  small  veins  into  the 
intercellular  matrix  of  the  pulp.  At  first  the  inflammatory  elements 
(leukocytes)  are  scattered  through  the  spaces  between  the  pulp  cells 
(Fig.  361);  at  a  later  stage  the  territory  is  occupied  by  round  indif- 


INFLAMMATION  OF  THE  PULP 


399 


ferent  cells  alone.    The  inflammation  may  be  widespread,  as  shown 
in  Fig.  362,  or  may  be  localized  to  some  portion  of  the  pulp,  as  one 


Fig.  362 


Interstitial  pulpitis  with  pulp  nodule  in  situ.      (V.  A.  Latham.) 

horn  of  a  pulp;  Black  noted  also  inflanmiatory  action  occurring  in 
small  islands  (Fig.  363). 

Fig.  36.3 


Minute  inflammatory  focus  within  the  tissues  of  the  pulp:  a,  a,  arterial  twigs; 
6,  a  ner\'e  bundle;  c,  collection  of  leukocytes.     (Black.) 


Swelling  of  the  pulp  (from  exudation)  cannot  occur  unless  there  be 
a  break  in  the  wall  of  the  pulp  chamber  through  which  additional 


400         DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

space  can  be  gained.  Black  has  recorded  that  "he  found  beneath  the 
layer  of  odontoblasts  in  the  region  of  an  exposure  an  unmistakable 
deposit  of  inflammatory  lymph.  The  case  had  a  history  of  severe 
toothache  for  two  days,  two  weeks  previously.  The  pulp  exhibited 
evidences  of  previous  extravasations  of  blood  from  hyperemia." 

There  is  evidence  that  the  pulp  may  recover  from  attacks  of 
inflammation,  and  that  resolution  occurs.  In  some  cases,  as  shown 
under  the  head  of  calcareous  degeneration,  the  tissues  may  become 
inflltrated  with  calcic  material.  In  others,  chronic  degenerative 
changes — inflammatory  degeneration — may  supervene. 

Suppuration  of  the  pulp  is  a  common  accompaniment  of  pulp 
inflammation;  this,  being  necessarily  infective,  will  be  described 
separately. 

GaskelU  has  reported  a  case  where  a  central  incisor  entirely  free 
from  caries  exhibited  on  its  palatal  aspect  a  pinkish  tinge,  which 
increased  in  depth  until  the  enamel  overlying  crushed  in,  revealing 
the  pulp  of  the  tooth  lying  immediately  beneath;  there  had  been  a 
resorption  of  a  large  mass  of  the  dentin  lying  between  the  pulp  and 
the  enamel.  The  pulp  was  removed  and  the  tooth  filled.  No  history 
is  given  as  to  the  condition  of  the  root,  whether  resorption  had 
occurred  there  or  not.  Shortly  after,  the  adjoining  central  incisor 
exhibited  a  like  pink  coloration,  which  increased,  leading  to  the 
inference  that  resorption  was  in  progress  in  this  tooth  also.  At  the 
suggestion  of  E.  C.  Kirk  the  patient  received  continued  doses  of 
arsenic  iodid  and  the  compound  syrup  of  the  hypophosphites,  in  the 
hope  of  inducing  a  general  and  local  constructive  metamorphosis. 
This  treatment  was  followed  by  a  gradual  disappearance  of  the  pink 
coloration,  an  evidence  of  a  redeposition  of  dentin.  In  the  absence 
of  histological  data  it  is  impossible  to  state  just  what  was  the  nature 
of  the  repair  tissue  in  this  particular  case,  but  Miller^  has  shown 
that  the  pulp  may  take  up  a  resorptive  function  and  remove  dentin 
which  may  later  be  redeposited  as  anomalous  tissue.  The  new 
dentin  does  not  contain  tubules,  but  has  the  characteristics  of 
cemental  tissue^  (osteodentin)  (Fig.  364).  This  process  has  its 
analogue  in  the  tusks  of  elephants  and  also  in  the  production  of 
Howship's  lacunae  in  the  resorption  of  the  pericementum,  these 
lacunse  later  being  filled  up  with  cementum. 

Resorption  of  the  walls  of  the  pulp  chamber  may  occur  as  an 
accompaniment  of  chronic  pulpitis.  What  appears  to  be  an  idio- 
pathic dentin  resorption  is  described  above.     Black  records  a  case 

'  Proceedings  of  the  Academy  of  Stomatology,  Philadelphia,  1895. 

^  Dental  Cosmos,  August,  1901. 

3  Hopewell-Smith:  Histology  and  Pathohistology  of  the  Teeth. 


INFLAMMATION  OF  THE  PULP 
Fig.  364 


401 


Resorption  of  the  walls  of  the  pulp  chamber  and  redeposition  of  new  calcific  matter : 
a,  pulp  chamber;  h,  c,  d,  portions  of  resorption  areas  not  refilled  and  walled  off  by  the 
new  deposit-forming  cavities  occupied  originally  by  the  pulp  tissue.     (Miller.) 


Fig.  365 


Acute  pulpitis:  S,  secondary  dentin;  B,  bay-Uke  excavations  filled  with  medullary 
or  inflammatory  corpuscles;  V,  transverse  section  of  a  bloodvessel;  M,  multinu clear 
body.     X  300.    (Bodecker.) 

26 


402  DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

where,  after  pulp  capping  in  a  lower  molar  and  the  insertion  of  a 
large  gold  filling,  the  tooth  was  examined  at  the  end  of  ten  years; 
for  two  or  three  years  the  pulp  had  given  evidences  of  irritability, 
and  when  the  pulp  was  removed  the  pulp  chamber  was  found  enor- 
mously enlarged  and  opening  into  the  pericementum  between  the 
roots  of  the  teeth.  Fig.  365  exhibits  resorption  of  previously  formed 
secondary  dentin  with  the  probable  agency  through  which  the 
resorption  is  brought  about.  The  area  of  resorption  is  invaded  by 
numerous  multinucleated  cells,  which  are  evidently  performing  the 
function  of  odontoclasts. 

There  have  been  cases  of  inflamed  pulp  in  teeth  decayed  while 
yet  impacted.  In  these  cases  there  is  usually  some  form  of  sinus 
connecting  the  tooth  with  the  mouth. 

Symptoms. — The  early  stage  of  inflammation  is  an  arterial  hyper- 
emia, and  as  the  leukocytes  collect  in  the  venules  a  venous  hyperemia 
is  established.  No  tnatter  how  far  the  area  of  stasis  extends,  beyond 
it  will  exist  an  area  of  arterial  hyperemia.  Owing  to  the  enclosing 
canal  walls  and  constricted  apex  a  general  venous  hyperemia  may  be 
established  which  causes  the  death  of  the  pulp. 

In  view  of  these  facts  it  is  not  surprising  that  the  symptoms  of 
pulp  inflammation  take  on  somewhat  the  characteristics  of  both 
arterial  and  venous  hyperemia.  The  diapedesis  of  leukocytes  and 
exudation  of  fluid  cause  the  phenomena  of  heavy,  boring  pain  and 
a  feeling  of  internal  pressure. 

The  pulp  may  be  exposed  and  no  symptoms  be  present.  A  sudden 
pressure  of  food  or  toothpick,  suction  upon  the  pulp  or  the  contact 
of  cold  or  hot,  salt,  sweet,  or  acid  substances,  may  excite  an  attack 
of  throbbing  or  lancinating  pain.  This  may  be  localized  in  the  tooth 
or  may  be  reflected  to  other  teeth  or  the  parts  mentioned  under 
hyperemia  (p.  382). 

The  assumption  of  the  recumbent  position  permits  an  increased 
flow  of  blood  into  the  paretic  vessels  of  the  pulp  and  increased 
suffering  results  in  correspondence  with  the  law  that  inflamed 
parts  are  always  more  painful  in  the  dependent  position.  Indeed, 
recumbency  is  sufficient  at  times  to  induce  a  paroxysm  in  a 
comparatively  quiet  but  inflamed  pulp.  Under  a  capping  or 
filling  pressing  on  the  pulp  or  thin  dentin  the  pain  may  begin 
as  a  slight  pain  and  gradually  increase  in  intensity,  or  it  may 
respond  as  a  sudden  agony,  beginning  even  some  time  after  the 
operation.  This  may  have  been  known  at  the  time  of  operation  or 
been  suspected  later.  In  one  typical  case,  violent  reflexes  occurred 
sometime  after  a  metal  filling  was  introduced  over  sound  dentin. 
The  diagnosis  was  uncertain  but  filling  removal  and  placement  of 


INFLAMMATION  OF  THE  PULP  403 

oxyeugenol  cement  for  a  month,  removed  the  reflexes,  permanent 
filling  was  done  and  after  four  years  no  trouble  exists — diagnosis, 
pressure  irritation.  In  the  later  stage  of  pulp  inflammation  the 
pain  is  of  a  heavy,  boring,  continuous  character,  the  pericementum 
becomes  somewhat  hj^eremic  (see  Fig.  354),  and  the  tooth  responds 
to  tapping.  In  case  of  a  highly  irritable  pulp,  however,  the  concussion 
of  the  pulp  produced  l)y  tapping  may  readily  cause  pain. 

In  pulpitis  the  pulp  responds  both  to  heat  and  cold.  There  have 
been  many  cases  of  reflex  neuroses  developed  by  inflamed  pulps, 
reflex  pains  in  the  face,  eye,  ear,  neck,  scalp,  chest,  arm,  heart,  etc., 
as  well  as  functional  disorders  of  the  eye,  ear,  and  brain;  a  large 
number  of  facial  neuralgias  are  due  to  this  condition  whether  the 
pulp  be  intact  or  partially  destroyed  as  in  pulp  abscess  or  ulceration. 
(See  Neuralgia.)  One  case  of  dementia  prsecox  was  cured  by  removal 
of  a  tooth  with  inflamed  exposed  pulp.^  Kauffmann^  cites  a  case  of 
aphasia  with  hallucinations  cured  by  removal  of  an  inflamed  pulp. 
One  case  of  sensory  paralysis  of  the  entire  left  side  was  caused  by 
inflammation  of  a  portion  of  the  pulp  in  a  right  upper  cuspid  and 
marked  relief  began  in  about  an  hour  after  removal  of  a  covering 
dressing  and  filling.  The  symptoms  of  suppurative  inflammation 
may  differ  somewhat.     (See  x^bscess  and  Ulceration,  p.  406). 

Diagnosis. — The  diagnosis  is  largely  inferential  and  made  by 
observation  of  the  symptoms  and  conditions  existing.  The  pulp 
may  be  exposed  or  closely  approached  by  caries,  or  the  pulp  may 
be  approximated  by  a  large  filling.  If  there  be  a  leak  about  the 
filling,  a  septic  fluid  or  actual  decay  beneath  the  filling  may  be  the 
exciting  cause.  In  the  absence  of  evident  causes  such  sepsis  is  always 
to  have  consideration,  and,  if  necessary,  the  filling  must  be  removed 
and  tests  applied.  The  more  obscure  causes,  such  as  abscesses  upon 
adjoining  teeth,  infection  from  the  pericemental  tract  in  the  course 
of  pyorrhea,  looseness  of  teeth  or  traumatisms,  are  to  be  carefully 
considered.  If  the  tooth  involved  be  uncertain,  each  tooth  should 
be  placed  under  rubber  dam  and  tested  thoroughly.  The  conditions 
are  either  obvious  causes  of  pulpitis  or  if  obscure  those  indicating 
hyperemia  are  to  be  carefully  considered  first.  Ordinarily  practical 
exposure  indicates  pulpitis  at  least  for  clinical  purposes  while  non- 
exposure  either  at  the  horn  or  apex  leads  to  inference  of  hyperemia  to 
be  further  tested  by  consideration  of  the  causes  (see  page  381),  and 
probably  by  treatment  as  for  hj-peremia.     If  this  is  not  successful 


>  Upson:  Dental  Cosmos,  1910,  p.  529. 
-  Dental  Cosmos,  November,  1916. 


404        DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

a  presumption  of  profound  venous  hjqDeremia  or  inflammation  exists. 
The  pulp  must  be  removed  in  either  of  the  latter  two  conditions. 

Prognosis. — The  prognosis  is  always  bad  for  the  comfortable 
conservation  of  the  pulp,  and  it  should  be  removed  and  the  canal  filled. 

Treatment.— The  treatment  of  pulpitis  involves  the  reduction  of 
the  amount  of  blood  in  the  vessels  of  the  pulp,  the  sterilization 
of  the  infected  area,  the  relief  from  the  pain,  and  the  removal  of 
the  pulp.  It  is  usual  to  excavate  the  cavity  of  decay  thoroughly 
enough  to  remove  from  over  the  pulp  decayed  dentin  which  would 
prevent  the  action  of  remedies  or  act  as  an  irritant.  The  cavity  is 
then  washed  and  a  sedative  applied.  (See  p.  391.)  A  creamy  paste 
of  bicarbonate  of  soda  in  carbolic  acid  has  been  recommended.  The 
use  of  chloroform  as  a  first  application  to  be  followed  by  eugenol 
when  the  pain  ceases  has  been  recommended  by  Shalet.^  The  addi- 
tion of  a  trifle  of  powdered  alum  to  any  of  the  sedatives  acts  as  an 
astringent  to  the  vessels.  During  the  half  hour  succeeding  the 
application  the  pulp  should  give  some  indication  of  relief.  If  it 
be  somewhat  decided,  a  portion  of  the  remedy  used  should,  if  pos- 
sible, be  sealed  in  the  cavity  for  twenty-four  hours.  The  covering 
may  be  prepared  first  as  for  arsenic  (q.  v.).  If  not  possible  to 
to  seal  it  in,  it  may  be  covered  with  cotton  saturated  with  a  varnish 
made  by  evaporating  tincture  of  benzoin.  This  varnish  hardens 
like  sandarac  varnish,  but,  unlike  it,  is  not  irritant.  Claims  are 
made  for  alcohol  used  as  for  pressure  anesthesia. 

If  after  the  first  half  hour  no  indication  of  relief  has  been  obtained, 
it  is  well  to  expose  the  pulp  and  to  relieve  the  engorged  vessels  by 
delicately  puncturing  it.  (See  Extirpation  of  Pulp.)  After  exposing 
the  pulp  it  will  perhaps  exude  a  bead  of  pus,  which  makes  the  diag- 
nosis one  of  pulp  suppuration.  After  free  bleeding,  which  may  be 
encouraged  by  means  of  warm  water,  the  sedatives  will  usually  act. 
It  may  be  necessary  at  times  to  employ  short  general  anesthesia 
(nitrous  oxid  gas,  etc.)  as  a  means  to  obtain  free  bloodletting.  Every- 
thing being  prepared,  the  patient  is  anesthetized  and  the  bulb  of  the 
pulp  cut  out,  or  if  N2O  and  O  anesthesia  can  be  used,  the  entire  pulp 
may  be  taken  out.  Conductive  anesthesia  may  be  used.  At  times 
cocain  pressure  anesthesia  is  effective  at  least  for  the  removal  of  the 
bulb  of  the  inflamed  pulp,-  and  sometimes  of  the  entire  pulp;  often, 
however,  it  causes  too  much  pain.  When  several  trials  have  been 
made,  and  even  the  cotton  forced  mto  the  pulp  tissue  without  com- 
plete anesthesia,  a  pellet  of  arsenical  devitalizing  fiber  may  be  put 
into  the  pulp  chamber  with  no  discomfort  as  a  rule. 

i  Dental  Digest,  March,  1917. 


INFLAMMATION  OF  THE  PULP  405 

In  case  of  partial  extirpation,  not  only  is  free  bleeding  induced, 
but  the  diseased  pulp  tissue  is  largely  removed.  When  hemorrhage 
ceases  arsenic  may  be  applied,  or  pressure  anesthesia  attempted. 
If  the  hemorrhage  be  obstinate  the  application  of  powdered  th^onol 
and  dried  alum  may  be  used.  (See  Venous  H}3)eremia.)  When 
sedatives  are  used  upon  the  pulp,  counterirritants  applied  to  the 
gum  are  aids  of  great  value,  and  are  to  be  used  as  described  under 
Arterial  Hj-peremia  (p.  391). 

In  addition  to  these  the  principle  of  depletion  may  be  employed. 
Deep  cuts  may  be  made  with  a  sharp  bistoury  in  the  gum  overljdng 
the  root  apex.  The  anastomosis  with  the  vessels  of  the  apical  tissue 
is  expected  to  cause  the  cuts  to  act  as  openings  made  in  veins  leading 
from  the  inflamed  pulp.  According  to  Nancrede,  depletion  on  the 
venous  side  of  an  inflamed  area  markedly  reduces  engorgement.  In 
addition  to  these  measures  catharsis  is  a  valuable  means  of  derivation; 
a  tablespoonful  of  sulphate  of  magnesia  is  to  be  dissolved  in  a  goblet 
of  water  and  taken  internally  at  least  a  half  hour  before  a  meal. 

If  the  pain  be  obdurate  and  its  return  feared,  two  |  grain  sulphate 
of  morphin  tablets  ma}^  be  dispensed,  preferably  by  the  operator, 
to  be  taken  only  in  case  of  severe  pain  and  an  hour  apart. 
Acetanilid  and  phenacetin,  aspirin,  trigemin  and  bromural,  o  grains 
each,  repeated  if  necessary,  are  also  useful. 

The  following  is  a  useful  anodyne  and  antineuralgic  prescription: 

I^ — Acetphenetidini  (phenacetin), 

Acetanilidi aa  gr-.  xxx 

Quininse  sulphatis gr.  xv — M. 

Pone  in  capsulas  no.  vi. 

S. — One  morning  and  evening. 

(See  also  Treatment  of  Facial  Neuralgia.) 

Hall^  has  suggested : 

I^ — Aspirin 3ss 

Codein gr.  iss 

M.  et.  ft.  chart.  No.  vi. 

Sig. — One  every  half-hour  until  relieved. 

Quiet  of  the  pulp  must  be  secured  before  an  arsenical  application 
is  made,  or  the  latter  merely  increases  the  irritation  instead  of 
promptly  devitalizing  (an  exception  is  noted  above).  Should  such 
an  irritation  occur  or  be  feared,  arsenic  ma}^  be  sealed  in  an  opening 
made  in  another  part  of  the  tooth  (a  "pocket"^),  with  a  view  to 
devitalizing  the  pulp  through  an  avenue  of  healthy  pulp  tissue.  At 
the  same  time  the  pulp  may  be  quieted  by  sedative  applications 
made  in  the  cavity  of  decay. 

Instead  of  drilling  a  special  pit,  the  arsenic  may  be  applied  at  a 

»  Dental  Cosmos,  1910,  p.  1085.  =  Flagg. 


406        DESTRUCTIVE  DISEASES  OF   THE  DENTAL  PULP 

portion  of  healthy  dentin  in  the  cavity,  which  is  at  some  distance 
from  the  orifice  of  exposure;  over  the  latter  the  analgesic  may  be 
placed  arsenic  pentoxid  has  been  suggested  by  Fette  as  being 
sedative  (see  Pulp  Removal). 


Fig.  366 


SUPPURATION    OF    THE   PULP. 

Definition. — By  suppuration  of  the  dental  pulp  is  meant  a  forma- 
tion of  pus  on  its  surface  (ulceration)  or  in  its  substance  (abscess). 
It  occurs  both  as  an  acute  and  as  a  chronic  afi'ection. 

Causes. — The  immediate  cause  of  suppuration  of  the  pulp  is  the 
ingress  of  pyogenic  organisms  to  the  pulp.     As  in  inflammation  of 

the  pulp,  while  usually  associated  with 
direct  exposure  of  the  pulp,  suppuration 
may  occur  in  pulps  covered  by  softened 
or  even  unsoftened  dentin. 

Arkovy^  first  observed  infection  of 
the  pulp  while  still  covered  by  a  layer 
of  unsoftened  dentin  (Fig.  366). 

Goadby  has  shown  that  microorgan- 
isms may  penetrate  even  secondary 
dentin,  a  condition  not  infrequently 
seen.  Miller  states  that  sections  of 
the  overlying  dentin  in  a  case  of  sup- 
puration of  the  pulp  showed  the  same 
forms  of  bacteria  as  were  found  in  the 
pulp  itself.  If  we  follow  Hartzell  and 
Henrici^  in  the  belief  that  streptococci  (brevis,  viridans)  are  the 
primary  agents  of  pulp  infection  and  staphylococci  secondary  agents, 
w'e  must  conclude  that  staphylococci  are  the  agents  of  the  suppur- 
ation. 

Bacteria  which  have  entered  the  body  through  w^ounds,  etc.,  may 
be  deposited  in  the  pulp  as  well  as  in  any  other  part  of  the  body, 
wherever  there  may  be  a  lessened  resistance  at  the  time.  While 
bacteria  may  thus  enter  from  the  circulation,  there  is  usually  abun- 
dant opportunity  for  their  entrance  from  the  mouth.  Suppuration 
of  the  pulp  is  a  not  infrequent  sequel  of  the  capping  of  pulps  which 
have  given  evidence  of  a  previous  h\'peremia  or  inflammation. 

Morbid  Anatomy  and  Pathology. — Anatomically  pulp  suppuration 
(purulent  or  pyogenic  pulpitis)  is  of  two  general  varieties:  one  begins 
upon  or  close  to  the  suface  of  an  exposed  pulp,  and  gradually  destroys 


Invasion  of  pulp   by   micrococci. 
(Arkovy.) 


1  Diagnostik  der  Zahnkrankheiten. 

2  Journal  of  National  Dental  Assn.,  May,  1917,  p.  487. 


SUPPURATION  OF  THE  PULP 


407 


the  organ  through  a  process  of  progressive  ulceration  (Fig.  367); 
the  second,  that  confined  in  the  substance  of  the  pulp,  causes  the 
gradual  destruction  of  a  part  of  the  pulp  through  the  formation  of 
circumscribed  abscesses  (Fig.  368). 

Ulceration  of  the  Pulp. — Of  these  two  forms,  ulceration  is  the 
more  common.  The  capillaries  (Fig.  367)  are  blocked  with  coagu- 
lated blood  (they  are  left  open  in  the  illustration  to  clearly  mark 
their  position);  the  intercapillary  meshwork  is  occupied  \)y  inflam- 

FiG.   367 


A,  diagram  of  lower  molar  with  caries  at  a  which  exposes  the  pulp;  the  darkened 
portion  at  b  shows  the  extent  of  the  inflammation;  the  rest  of  the  organ  was  free  from 
inflammatory  change.  B,  illustration  of  the  inflamed  tissue,  showing  a  part  destroyed 
by  suppuration  at  a;  the  odontoblasts  are  undermined  at  b;  the  bloodvessels  which 
were  filled  with  blood  clot  in  the  section  are  left  blank  here,  that  they  may  be  more 
apparent.     (Black.) 


matory  exudation;  the  surface  of  the  pulp  is  eroded  and  covered  with 
pus  corpuscles;  the  ulcerative  process  is  undermining  the  layer  of 
odontoblasts.  The  suppurative  process  penetrates  the  body  of  the 
pulp,  following  the  direction  of  its  veins  and  hollowing  out  the  organ 
into  a  deep  cavern.  Black  regards  the  persistence  of  the  layer  of 
odontoblasts  as  indicating  an  inferior  vitality,  as  it  shows  they  are 
less  susceptible  of  change  of  form  than  the  other  cells  of  the  organ. 
The  process  of  ulceration  may  continue  for  weeks  or  months  until 


408 


DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 


the  entire  organ  has  been  destroyed  molecularly.  The  necrotic  por- 
tions undergo  putrefactive  decomposition,  probably  passing  through 
the  same  stages  that  any  albuminous  substance  passes  in  its  serial 


Fig.  368 


Acute  suppurative  pulpitis  in  the  coronal  portion;  /,  intensely  inflamed  horn;  A, 
abscess;  V,  bloodvessels  engorged  -ndth  blood;  >S,  superficially  inflamed  horn;  A'^,  nest 
of  inflammation.     X  10.     (Bodecker.) 


decomposition,    into   the    end-products — ammonia,    carbon   dioxid, 
hydrogen  sulphid,  and  water, 

I  have  observed  cases  of  vital  but  finally  ulcerated  pulps  under 


SUPPURATION  OF  THE  PULP 


409 


Fig.  369 


Crowned  lower  molar  with  pulp 
filaments  vital  for  fifteen  years. 


canal  fillings.  In  one  case  twelve  years  had  elasped  between  the 
partial  canal  filling  and  the  more  recent  observation.  In  another 
case  in  which  temporary  stopping  had  been  packed  upon  vital 
filaments  fifteen  years  passed  before  I  opened  and  found  them. 
There  were  no  symptoms  and  I  supposed  the  tooth  devitalized 
because  the  pulp  cavity  appeared  to  be  filled  (Fig.  369). 

Symptoms. — If  the  cavity  of  decay  be  open  the  pus  and  serous 
exudate  may  freely  escape,  so  that  the  symptoms  may  not  exceed  a 
dull,  gnawing  pain,  which  is  usually  re- 
flex in  character. 

As  a  rule,  the  response  to  cold  will  be 
much  delayed  or  even  absent.  Intense 
pain  may  exist  when  the  pus  cannot 
find  exit  owing  to  food  debris  being 
massed  in  the  pulp  chamber,  or  owing 
to  the  presence  of  a  filling  or  mass  of 
secondary  dentin.  The  case  then  re- 
sembles and  practically  becomes  one  of 
abscess  of  the  pulp. 

The  chief  diagnostic  feature  of  pulp 
ulceration  is  the  presence  of  the  sub- 
acute inflammatory  symptoms  described  above  and    the  presence 
of  a  pulp  partially  removed  by  decomposition  of  its  upper  portion. 

Thus  if  the  pulp  chamber  be  open  at  one  horn,  and  a  probe  may 
be  passed  into  it  for  a  short  distance  until  it  comes  into  contact  with 
an  irritable  portion  of  pulp,  and  when  withdrawn  have  the  odor  of 
putrefaction,  the  diagnosis  is  clear — loss  of  pulp  substance  by  putre- 
factive changes,  presumably  by  suppuration.  In  some  teeth  it  may 
be  by  partial  gangrene.  Many  phases  of  this  condition  may  be  seen; 
thus  in  an  extreme  case  one  canal  of  a  lower  molar  contained  a  highly 
irritable  vital  filament  of  pulp  extending  but  one-quarter  inch  from 
the  apical  foramen;  a  second  canal  was  entirely  occupied  by  a  per- 
fectly vital  but  ulcerating  filament;  the  third  canal  contained  an 
entirely  dead  pulp.  The  bulb  of  the  pulp  had  disappeared,  doubtless 
by  suppuration. 

Treatment. — The  treatment  of  pulp  ulceration  in  its  early  stages 
involves  the  opening  of  the  orifice  of  exposure,  the  sterilization  of 
the  superfices  of  the  pulp,  and  pulp  removal. 

Superficial  sterilization  may  be  accomplished  by  removing  the 
pus  or  putrefactive  material  present  by  means  of  warm  3  per  cent, 
hydrogen  dioxid.  The  saturated  solutions  of  thymol  in  alcohol  or 
menthol  in  chloroform,  or  2  per  cent,  formaldehyd  or  formocresol 
diluted  to  3  per  cent,  formaldehyd  strength  with   eugenol  may  be 


410        DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

sealed  in  position  against  the  pulp  for  twenty-four  hours  as  an  anti- 
septic. I  have  even  used  pure  formocresol  in  the  pulp  chamber  with- 
out irritation,  sometimes  erroneously  having  diagnosed  putrefactive 
pulp,  but  later  the  vital  filaments  were  discovered.  The  application 
of  arsenic  may  then  be  safely  made.  In  favorable  cases  the  bulb  of 
the  pulp,  or  even  the  entire  pulp,  may  be  removed  at  the  first  or  second 
sitting  by  means  of  cautiously  applied  cocain  and  phenol  pressure 
anesthesia.  In  some  cases,  however,  the  patient  will  rebel. 

When  a  part  of  the  canal  filament  alone  remains  after  treatment 
to  remove  bacteria,  the  pressure  anesthesia  may  be  resorted  to.  A 
long  thread  of  cotton  is  saturated  with  carbolic  acid  or  carbolic  acid 
and  cocain,  and  gently  packed  into  the  canal  against  the  pulp  fila- 
ment. Pressure  with  vulcanizable  rubber  is  now  produced,  and  after 
a  few  minutes  the  pulp  will  be  sterilized  and  anesthetized  sufficiently 
for  removal.  It  is  better  to  treat  each  canal  separately  as  a  general 
pressure  will  probably  fail.  Puncturing  is  also  useful  at  times. 
Arsenic  may  be  cautiously  placed  on  cotton  half-way  up  a  canal 
against  such  a  pulp  filament.  Another  method  consists  of  packing 
a  thread  of  cotton  dipped  in  carbolic  acid  tightly  against  the  fila- 
ment, in  which  thrombosis  is  thus  induced.  (See  also  Methods  of 
Pulp  Removal.) 

Abscess  of  the  Pulp.- — Abscess  of  the  pulp  is  usually  situated  near 
the  point  of  exposure  of  the  organ.  It  may  be  confined  to  one  horn 
of  the  pulp,  or  may  involve  nearly  the  entire  substance  of  the  pulp, 
the  peripheral  tissue  of  the  pulp  being  unbroken.  Abscess  may  exist 
at  some  distance  beneath  the  surface  of  the  pulp,  and  the  latter  be 
still  covered  with  a  layer  of  dentin.  Burchard  once  uncovered  the 
horn  of  a  molar  pulp  which  was  covered  by  a  lamina  of  hard  dentin, 
and  no  fluid  appeared;  but  upon  passing  a  sharp  probe  into  the  white 
area  of  exposure  for  over  one-eighth  of  an  inch  or  more  there  was  a 
free  flow  of  pus  which  quickly  filled  the  larger  carious  cavity.  A  pulp 
removed  entire  from  a  tooth,  and  which  was  yellowish  white  in  color 
and  unbroken,  showed  upon  section  its  interior  hollowed  out  into  an 
enormous  abscess  cavity  (Fig.  370).  The  bloodvessels  were  blocked; 
the  peripheral  tissues  were  unaltered;  between  the  odontoblasts  and 
the  abscess  cavity,  the  latter  lined  with  pus  corpuscles,  evidences  of 
inflammation  w^ere  plenty.  In  some  cases  pus  flows  upon  removing 
a  last  layer  of  dentin,  a  pulp  capping,  filling,  etc.  While  technically 
this  is  ulceration,  being  superficial,  yet  a  cavity  is  circumscribed  and 
contains  pus  so  that  the  condition  and  symptoms  are  those  of  abscess 
of  the  pulp.  Black  found  that  the  odontoblasts  retained  their  form 
after  neighboring  cells  of  the  pulp  had  been  destroyed. 


SUPPURATION  OF  THE  PULP 


411 


Miller's^  researches  show  a  preponderance  of  cocci  and  micrococci 
in  cases  of  enclosed  abscess;  cocci  and  diplococci  were  of  constant 
occurrence.  Many  of  the  forms,  both  cocci  and  bacilU,  were  cultivable 
upon  gelatin  and  agar-agar.  Some  of  them,  cocci  and  bacilli,  brought 
about  the  liquefaction  of  gelatin;  others  did  not.  So  that  it  must  be 
inferred  that  infective  inflammation  and  necrosis  of  the  pulp  may 
occur  without  suppuration.  (See  Gangrene  of  the  Pulp.)  In  some 
instances  streptococci  were  found.  In  the  freely  exposed  pulps 
varieties  of  organisms  were  found  which  would  render  clear  the 
possibility  of  a  general  infection  by  way  of  the  dental  pulp. 

Fig.  370 


Transverse  section  of  inferior  bicuspid  pulp,  one-half  diagrammatic:  a,  abscess 
cavity;  b,  embryonic  cells  at  the  periphery  of  the  abscess  cavity;  c,  occluded  blood- 
vessels.   (Burchard.) 


Symptoms. — The  usual  symptoms  are  as  follows:  In  a  tooth  con- 
taining an  enormous  filling,  one  in  which  the  pulp  has  been  exposed, 
or  nearly  so,  or  in  a  tooth  having  a  large  carious  cavity,  the  patient 
gives  a  history  of  discomfort  or  decided  pain,  appearing  at  intervals, 
sometimes  appearing  and  disappearing  suddenly,  the  existing  condi- 
tion having  been  ushered  in  by  dull,  gnawing  pain,  which  is  usually 
not  positively  located,  although  it  may  be.  The  pain  grows  in 
intensity,  and,  in  contradistinction  to  the  pulp  conditions  previously' 
described,  pain  is  relieved  instead  of  increased  by  applications  of  cold. 
It  may  be,  however,  that  the  prolonged  contact  of  iced  water  may 
induce  a  response.    The  response  to  heat  is  marked,  so  that  a  mouth- 

1  Dental  Cosmos,  1894. 


412 


DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 


Fig.  371 


fill  of  hot  cofi'ee  or  even  the  warmth  of  the  tongue  may  precipitate  an 
attack  of  severe  and  continued  pain.  Pain  produced  upon  passing 
from  a  warm  to  a  cold  atmosphere,  and  vice  versa,  is  also  symptomatic. 
If  the  pulp  be  freely  exposed  and  pricked  with  a  sharp  instrument,  a 
flow  of  pus  follows  in  many  cases,  and  the  relief  is  almost  immediate. 
In  the  earlier  stages  a  period  of  throbbing  pain  may  follow  evacu- 
ation of  the  pus.  In  some  cases  a  very  minute  portion  of  odorous 
liquid  may  be  found  at  a  very  fine  exposure. 

In  other  cases  the  response  to 
heat  may  decrease  until  it  is  almost 
absent,  and  the  case  only  be  seen 
when  evidences  of  the  action  of 
bacterial  products  upon  the  peri- 
cementum appear,  which  they 
usually  do  in  the  later  stages  of 
pulp  suppuration,  when  the  tooth 
becomes  loose,  extruded,  and  tender 
upon  percussion. 

The  symptoms  of  pericemental 
disturbance  may  simulate  those  of 
incipient,  acute,  apical  abscess, 
even  though  a  quarter  of  an  inch  or 
more  of  apical  pulp  tissue  exist 
in  a  vital  though  highly  inflamed 
condition.  Upon  clinical  evidence  it  is  assumed  that  the  inflammation 
of  the  pulp  produces  inflammation  of  the  apical  tissue,  or  that  the 
infection  travels  to  the  apical  tissue  (Fig.  371.)  In  one  case  the  gum 
and  contiguous  parts  about  an  upper  molar  were  swollen,  apical 
abscess  diagnosticated,  and  a  free  flow  of  pus  followed  by  blood 
obtained  upon  opening  the  crown.  An  examination  made  twenty- 
four  hours  later,  after  symptoms  had  subsided,  demonstrated  all 
three  pulp  filaments  to  be  alive  when  a  post  hoc  diagnosis  of  extensive 
abscess  of  the  pulp  was  made.  If  untreated,  symptoms  of  pulp  and 
pericemental  disturbance  may  disappear  for  weeks  or  months;  but 
if  the  parts  be  not  perfectly  sterilized  and  reinfection  prevented,  it 
is  only  a  question  of  time  when  septic  pericementitis  will  arise. 

Diagnosis. — The  most  valuable  diagnostic  symptoms  are  (1)  the 
peculiar  increasing  reaction  to  applications  of  heat  and  relief  from 
cold;  (2)  the  sudden  appearance  and  disappearance  of  the  pain — 
often  while  in  the  office;  (3)  the  response  to  change  of  atmosphere,  all 
of  which  are  confirmed  by  opening  and  finding;  (a)  a  bead  of  pus  on 
the  pulp  surface;  (6)  a  fine  insensitive  horn  evidently  putrefactive  with 
vitality  beneath  as  it  is  explored;  (c)  pus  upon  puncturing  the  pulp. 


Abscess  of  the  pulp  after  forma- 
tion of  a  large  amount  of  secondary 
dentin,  dividing  the  pulp  into  two 
portions:  SD,  secondary  dentin;  A  P, 
abscess  or  confined  pus;  V  P,  ^^tal 
pulp;  /,  area  of  apical  inflammation. 
(Diagrammatic.)  (After  ease  in  the 
mouth.) 


SUPPURATION  OF  THE  PULP 


413 


In  cases  where  several  teeth  are  involved  in  the  diagnosis,  differ- 
entiation is  made  by  isolation  of  each  tooth  by  means  of  a  small 
square  of  rubber  dam.    The  thermal  test  is  then  applied.    The  pres- 


FiG.  372 


Chronic  suppurative  pulpitis  terminating  in  calcification  of  the  pus  and  atrophy  of 
the  pulp:  A^,  larger  abscess,  filled  with  calcified  pus;  A^,  abscess  at  the  periphery  of 
the  pulp;  A^  A^,  smaU  longitudinal  abscesses,  all  calcified;  N,  calcified  nerve  bundle; 
C,  C,  calcareous  depositions  in  the  fibrous  pulp  tissue;  P,  P,  pigment  clusters  from 
previous  hemorrhage.      X  10.     (Bodecker.) 


ence  of  a  quantity  of  secondary  dentin  will  confuse  by  causing  dulness 
of  response.  In  such  case  the  electric  test  should  be  resorted  to. 
It  may  fail  if  much  pus  be  present  in  which  case  the  electric  light 


414        DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

should  show  opacity.  (See  Dry  Gangrene.)  In  some  cases  secondary 
dentin  will  have  formed  in  the  pulp  cavity  and  the  abscess  may  be 
found  in  one  of  the  filaments,  while  the  other  will  be  apparently 
healthy.  Fig.  371  is  a  diagram  of  a  number  of  cases  seen  in  practice. 
It  is  to  be  remembered  that  the  expansion  of  the  gas  by  heat  with 
symptoms  of  pain  is  common  to  all  cases  with  gas  confined,  whether 
a  pure  pulp  abscess,  a  partial  gangrene  (putrefactive)  or  even  total 
gangrene  with  apical  irritability.  Therefore  one  should  be  prepared 
to  modify  the  tentative  diagnosis  according  to  the  condition  found 
on  investigation  after  opening,  which  is  always  warranted. 

Prognosis. — General  experience  regards  ulceration  and  abscess  of 
the  pulp  as  precursors  of  the  death  of  the  organ.  Usually  this  is 
by  progressive  suppuration.  It  is  undoubtedly  true,  however,  that 
attempts  at  circumvallation  of  the  dead  tissue  are  made  in  some 
cases  (Fig.  371).  The  pus  cells  undergo  degeneration  and  the  abscess 
site  may  be  the  seat  of  calcareous  deposits.  Even  in  these  cases 
death  is  delayed,  not  averted.  The  remainder  of  the  pulp  under- 
goes atrophic  changes,  and  commonly  suppuration  reappears. 

Treatment. — The  treatment  of  the  case  consists  in  relieving  the 
existing  pain,  completing  the  devitalization  of  the  pulp,  and  removing 
it  in  such  a  manner  that  no  organisms  or  dead  matter  are  carried 
beyond  the  apex  of  the  root. 

To  secure  relief,  evacuation  of  the  pus  is  imperatively  necessary. 
The  organ  is  freely  exposed,  exercising  no  pressure  in  gaining  free 
access  to  it.  If  pus  does  not  flow  upon  exposure  of  the  surface  of 
the  pulp,  a  sharp,  slender,  sterilized  probe  is  quickly  passed  into  the 
substance  of  the  pulp,  when,  if  pus  be  present,  it  will  usually  escape 
freely  through  the  opening  thus  made  and  be  followed  by  blood. 

Throbbing  pain  may  follow,  which  a  sedative  promptly  quiets. 
The  application  is  not  made  until  the  pus  flow  ceases.  One  of  the 
sedatives  mentioned  for  ulceration  (page  409)  is  laid  upon  the  pulp 
and  the  cavity  is  sealed  for  twenty-four  hours  (never  longer),  and 
then  the  pulp  is  removed.  Should  the  exposed  portion  of  the  pulp  be 
insensitive  it  is  cut  away  until  access  is  had  to  the  vital  portion, 
where  the  arsenic  is  to  be  applied.  The  pulp  may  sometimes  be 
anesthetized  by  cocain  for  removal.  The  rubber  dam  need  not 
necessarily  be  applied  for  the  treatment  preliminary  to  devitalization, 
but  the  pulp  should  be  kept  under  the  influence  of  antiseptics.  As 
these  may  be  obstinate  cases  the  pulp  may  be  removed  surgically  or 
at  least  the  bulb  may  be  removed,  using  anesthesia  as  described  on 
pages  312,  etc.) 


CHRONIC  INFLAMMATION  OF  THE  PULP 


415 


CHRONIC   INFLAMMATION    OF    THE    PULP. 

In  cases  in  which  the  resistive  force  of  the  pulp  is  great  and  the 
causes  of  less  violent  nature  or  less  violent  in  action,  the  inflammation 
may  be  of  low  grade  and  continue  for  some  time.  Pulp  ulceration 
may  pursue  a  chronic  course,  as  has  already  been  described.  Abscess 
of  the  pulp  may  also  become  chronic,  and  the  pulp  may  even  encap- 
sule  the  pus  area,  and,  the  bacteria  dying,  the  abscess  area  may 
become  the  seat  of  calcareous  deposits. 

Fig.  373 


Chronic  inflammation  of  the  pulp,  areolation,  and  degeneration      (Black.) 


Sclerosis  of  the  Pulp. — Inflammation  of  a  low  grade  may  persist 
in  the  pulp  for  long  periods,  giving  rise  to  an  increase  of  its  fibrous 
tissue  with  atrophy  of  the  cellular  elements,  producing  a  condition 
found  in  chronic  interstitial  inflammation  in  some  other  tissues — a 
sclerosis.  Instead  of  the  usual  distribution  of  myxomatous  tissue, 
bands  and  bundles  of  fibrous  tissue  appear.  The  pulp  appears 
shrunken  and  stiff,  bloodvessels  are  contracted  and  sclerotic,  and 
the  nerve  fibers  have  undergone  partial  or  complete  atrophy  and 
degeneration  (Fig.  373). 

Black  found  that  in  the  late  stages  of  sclerotic  atrophy  areolae 
developed  in  the  bundles  of  connective  tissue,  the  inflammatory 
elements  having  disappeared  and  the  areolae  being  occupied  by 
fluid.  Arkovy  describes  the  condition  as  reticular  atrophy  of  the 
pulp. 

Sclerotic  and  other  chronic  degenerations  of  the  pulp  usually 
present  the  history  of  one  or  more  attacks  of  pulpitis  in  the  past, 
with  more  or  less  continuous  uneasiness  extending  over  a  long  period. 
The  response  of  the  pulp  to  all  tests  becomes  diminished  and  dull. 
The  condition  cannot  be  diagnosed  before  pulp  removal. 

Treatment. — Such  pulps  are  to  be  devitalized  and  removed. 

Chronic  Hyperplastic  (Hypertrophic)  Pulpitis. — When  the  pulp 
is  exposed  over  a  wide  area,  long-continued  chronic  inflammation 


416        DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

may  lead  to  an  enlargement  of  the  organ  with  a  protrusion  of  an 
altered  pulp  mass  through  the  orifice  of  exposure,  producing  the 
condition  known  clinically  as  fungous  pulp.  When  the  growth 
extends  beyond  the  boundaries  of  the  orifice  and  then  increases  in 
bulk  it  forms  a  pedunculated  mass  to  which  the  term  polypus  of  the 
pulp  has  been  applied. 

Fig.  374 


Pulpitis  arteriosclerosis;  nerve  degeneration.     (V.  A.  Latham.) 


Morbid  Anatomy  and  Pathology. — The  growth  has  its  origin  in  a 
chronic  inflammation  of  the  body  of  the  pulp;  the  organ  swells,  and 
contact  with  the  sharp  edges  of  the  orifice  of  exposure  excites  a 
continued  irritation,  leading  to  further  proliferation  of  the  cells  of 
the  inflamed  part,  so  that  a  large  mass  of  embryonic  tissue  is  formed 
(Fig.  375),  termed  by  Black  granulation  tissue  of  a  low  type.  As  in 
the  granulation  tissue  of  repair,  bloodvessels  grow  into  this  mass, 
so  that  it  may  bleed  at  a  slight  touch.  Black  noted  in  his  case  illus- 
trated, a  covering  of  squamous  epithelium  upon  the  periphery  of  the 
growth,  which  might  be  interpreted  as  the  transformation  of  meso- 
blastic  into  epiblastic  tissue,  but  the  correct  explanation  beyond 
doubt  is  that  advanced  by  the  same  author,  that  the  epithelium  is 
transplanted  from  the  gums,  and  grows  after  the  manner  of  a  skin 
graft.  The  growth  does  not  contain  nerves.  The  cavity  in  which  it 
lies  is  often  fairly  free  from  decalcified  dentin,  the  walls  appearing  as 


CHRONIC  INFLAMMATION  OF  THE  PULP 


417 


though  subjected  to  an  absorbent  action.  Black  ascribes  this  to  the 
action  of  saprophytic  bacteria  upon  the  decalcified  dentin,  but  other 
cln-onically  inflamed  hj-perplastic  pulps  have  absorbent  action  (see 
page  400)  and  there  is  no  good  reason  to  make  this  an  exception, 
though  of  course  there  is  no  means  of  proof. 


Fig.  375 


A,  a  first  lower  molar  with  a  cavity  at  a  completely  filled  by  an  hypertrophy  of  the 
pulp,  which  has  grown  out  through  the  orifice,  exposing  the  pulp  at  b.  B,  a  field 
illustrating  the  tissue  of  the  growth,  which  is  composed  almost  entirely  of  granulation 
tissue  of  a  very  primitive  type;  a,  a  covering  of  epithelium  presenting  papillae;  b, 
epithelium  apparently  without  papillae.    (Black.) 

These  growths  may  undergo  further  changes;  higher  organization 
of  the  granulation  tissue  occurs  and  fibrous  tissue  is  formed;  the  cells 
may  undergo  degenerations,  first  granular,  then  fatty,  and  suppura- 
tion and  gangrene  may  occur.  Tomes^  records  a  case  where  calci- 
fication of  an  hypertrophied  section  of  a  pulp  occurred;  but  as  the 
case  was  due  to  traumatism  (fracture  of  a  tooth),  different  vital 
conditions  existed  from  those  in  the  cases  under  discussion.  (See  page 
361.)  Actual  calcification  of  the  mass  is  scarcely  possible,  although 
calcareous  degeneration  ma}'  occur  within  the  fmigous  mass  (Fig. 
376,  G).    These  tissues  seem  to  have  an  inherent  vitality  peculiar  to 


27 


Dental  Surgery,  third  edition. 


418        DESTRUCTIVE  DISEASES  OF   THE  DENTAL  PULP 


the  patient.    I  have  seen  cases  of  separated  portions  of  pulp  all  vital 
with  one  liA'pertrophic  or  with  one  hypertrophic  and  the  other  dead. 


M— 


Hjijerplastic  rojrxomatous  pulp,  which  filled  a  carious  ea\'ity:  M,  lobules  made  up 
of  papillEe  of  a  myxomatous  structure,  rich  in  capillary  and  venous  bloodvessels;  G, 
calcareous  globule;  E,  epithelial  cover  of  papillse.     X  10.     (Bodecker.) 


Fig.  377 


Fig.  .378 


Fig.  379 


Fig.  380 


Hypertrophy  of  pulps.   (Garretson.) 

As  shown  by  Miller,  Hopewell-Smith,  and  others,  a  reconstructive 
change  may  occur  and  adventitious  dentin  be  redeposited  in  the 
area  of  resorption  (Fig.  364). 


CHRONIC  INFLAMMATION  OF  THE  PULP  419 

Symptoms, — The  s}Tiiptoms  of  chronic  pulp  inflammations  and 
degenerations  are  usually  those  of  long-continued  discomfort,  with 
reflex  pains,  which  rarely  persist  into  the  latest  stages  of  degeneration. 
The  response  to  heat  and  cold,  present  at  first,  declines  until  the 
pulp  scarcely  reacts,  and  then  but  slowly. 

No  nerve  fibers  develop  in  the  hypertrophic  pulp  tissue,  so  that 
the  newgrowth  has  no  sensitivity  in  itself,  although  pressure  upon  it 
may  cause  sharp  pain  through  the  still  vital  pulp  nerves  themselves. 

Four  or  five  of  these  hypertrophies  may  exist  in  a  mouth,  filling 
whole  cavities  of  decay,  the  surrounding  tooth  structure  being  in 
various  stages  of  disintegration.  They  seem  to  be  comparatively 
insensitive  to  mastication  (Fig.  378). 

Fig.  381  Fig.  382 


Hypertrophy  of  the  gum.  Hypertrophy  of  the  pericementum. 

(Garretson.)  (Garretson.) 

Hypertrophy^  of  the  pulp  also  may  be  associated  with  pulp  ulcera- 
tion, the  growth  arising  from  one  canal  of  a  tooth. 

Regeneration  of  an  extirpated  pulp  has  been  claimed.  These  are 
probably  referable  to  the  above  form  of  hypertrophy,  or  to  a  fungoid 
growth  from  the  pericementum  or  supposed  extirpation  under  cocain. 

Diagnosis. — The  only  condition  with  which  hypertrophic  pulp  may 
be  confounded  is  a  pedunculated  growth  of  gum  tissue  through  a 
cavity  at  the  neck  of  a  tooth  beneath  the  gum  margin,  or  through 
a  perforation  either  accidental  or  by  caries  (Fig.  382).  It  is  impor- 
tant to  differentiate  between  these  conditions,  because,  if  an  appli- 
cation of  arsenical  paste  be  made  to  a  fungous  gum,  the  destruction 
of  tissue  may  extend  into  the  sound  pericementum.  The  physical 
appearances  of  the  two  are  alike;  they  both  bleed  freely  and  have 
about  the  same  degree  of  sensitivity. 

Histological  examination  of  this  class  of  hypertrophy  of  the  gums, 
conducted  by  Dr.  Luigi  Ancone,^  of  Italy,  demonstrated  that  the 
growth  is  a  simple  exaggeration  of  the  normal  elements  of  the  part. 
Occasionally  a  sarcomatous  growth  arises  in  this  region,  i.  e.,  from 
the  EQarginal  pericemental  tract  and  if   not  self-explainable  as,  for, 

1  Abstract  from  I'Odontologia,  by  Dr.  W.  Dunn,  in  International  Dental  Journal,  1899, 


420        DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

example,  in  Fig.  382,  and  not  rapidly  amenable  to  treatment  calls 
for  a  resection  of  a  portion  of  the  bone. 

If  the  tumor  be  central  to  the  tooth  tissue  and  the  latter  not 
decayed  out  to  very  thin  walls,  it  may  be  at  times  laid  aside  by  means 
of  a  blunt  instrument  and  be  seen  to  have  its  origin  from  an  orifice  of 
exposure  (Fig.  377).  As  a  rule,  a  hyperplastic  pericementum  will 
be  found  to  have  its  attachment  much  lower  or  more  lateral  than 
'  a  hyperplastic  pulp,  and  the  pulp  cavity  be  seen  to  have  been  enlarged 
by  caries,  even  more  than  shown  in  Fig.  300.  It  is  then  fairly  inferred 
to  be  a  gum  mass,  especially  if  the  tooth  has  never  been  operated 
upon.  The  diagnosis  may  be  a  doubtful  one,  in  which  case  the 
rubber  dam  is  to  be  applied,  the  polypus  frozen  by  means  of  a  spray 
of  ethyl  or  methyl  chlorid,  and  the  mass  removed  with  a  sharp 
blade  passed  across  its  peduncle.  The  electric  cautery  may  preferably 
be  used  to  ablate  the  mass.  Local  anesthesia  may  be  used  in  con- 
junction to  eliminate  pain  or  even  for  removal  of  the  pulp. 

The  source  of  the  tumor  may  then  be  usually  clearly  seen.  As  an 
alternative  proceeding  the  tissue  may  be  thoroughly  saturated  with  a 
strong  solution  of  trichloracetic  acid  and  then  ablated.  If  any  fur- 
ther doubt  exist,  the  pulp  is  to  be  sterilized  with  hydrogen  dioxid,  etc., 
and  a  pellet  of  cotton  saturated  with  oil  of  cloves,  carbolic  acid,  or 
dental  tincture  of  iodin  is  laid  upon  it,  and  over  this  temporary  stop- 
ping is  firmly  packed,  or  cotton  and  sandarac  first  dipped  in  ortho- 
form  may  be  used.  By  this  means  the  growth  may  be  pressed  away 
until  it  is  seen  to  arise  from  either  a  pulp  chamber  or  a  perforation 
made  by  decay  or  accidental  excavation  into  the  pericemental  tract. 

Radiography  should  aid  in  the  diagnosis.  Hemorrhage  may  be 
checked  with  alum  and  thymol  in  powder  or  solution,  or  by  the  use 
of  trichloracetic  acid,  silver  nitrate,  zinc  chlorid,  or  iodin. 

Treatment. — If  the  case  be  one  of  pulp  hypertrophy,  arsenic  may 
be  applied  or  local  anesthesia  attempted  for  pulp  removal. 

Crystals  of  iodin  have  been  used  with  satisfaction  in  combination 
with  pressure  for  pulp  devitalization.^  If  a  perforation  exist,  it  is  to 
be  treated  by  sealing  the  orifice  with  gutta-percha,  copper  amalgam, 
or  oxyphosphate  of  copper  cement.    (See  page  300.) 

Infarction  of  the  Pulp.— The  production  of  infarction  may  result 
(see  page  393),  and  as  described  consists  of  minute  circiunscribed 
hemorrhages  from  end  arteries  into  the  pulp  tissue.  This  differs 
somewhat  from  a  true  infarction  (Fig.  383).     It  cannot  be  diagnosed. 

Fibroid  Degeneration  of  the  Pulp. — Apart  from  the  degenerations 
due  to  inflammatory  conditions,  a  form  of  degeneration  occurs  "as  a 

'  Dr,  James  Truman. 


CHRONIC  INFLAMMATION  OF  THE  PULP 


421 


natural  old-age  termination  of  the  life  of  a  healthy  pulp,  and  similar 
to  senile  changes  occurring  in  the  pericementum."  (See  Fibroid 
Degeneration  of  Pericementum).  This  change,  as  described  by 
Hopewell-Smith, 1  occurs  in  teeth  of  the  aged  in  whose  mouths  simple 
alveolar  resorption  has  occurred,  though  later  he^  has  shown  that  it 

Fig.  3S3 


H,  hemorrhagic  infarct;  R,  rupture  of  bloodvessel;  D,  dentin;  O,  vacuolated  odonto- 
blasts; F,  early  fibrosis  of  pulp.    X  250.   (Hopewell-Smith.) 

may  occur  in  the  pulps  of  young  persons,  in  sound  teeth  extracted 
for  irregularity,  and  even  in  teeth  in  which  the  dentinal  wall  or  pulp 
cavity  is  not  completed  to  a  t}^ical  calcification.  He  regards  it 
as  due  to  a  primary  thrombosis  of  the  capillaries  and  veins,  with 
permanent  dilatation  of  the  arteries,  with  or  without  tiny  hemor- 
rhages,   the   lack    of    collateral    circulation    and    lymphatics    con- 


1  Histology  and  Pathohistology  of  the  Teeth. 


2  Dental  Cosmos,  1907. 


422 


DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 


tributing  to  the  atrophy.    As  a  cause  he  suggests  chemical  change 
in  the  blood  through  systemic  derangement,  as  anemia,  chlorosis, 


Fig.  384 


Horizontal  section  of  fibroid  degeneration  of  the  pulp  in  situ.  Prepared  by  Mr. 
Hopewell-Smith's  process:  D,  deeply  stained  dentin;  S,  large  areolar  spaces;  DO, 
degenerate  odontoblasts;  P,  fibroid  tissue  of  pulp.     X  45.     (Hopewell-Smith.) 


or  exhaustive  diseases,  the  red  corpuscles  being  fewer  and  the 
leukocytes  and  blood  platelets  increased,  thus  favoring  a  thrombosis 
of  small  vessels;  also,  that  here  inflammatory  changes  in  the  peri- 


CHRONIC  INFLAMMATION  OF  THE  PULP 


423 


cemental  tissue  might  interfere  with  the  pulp  circulation  sufficiently 
to  produce  it. 

Clinical  Significance. — While  the  form  of  thrombosis  or  fibrosis 
may  not  be  diagnosed  because  of  lack  of  related  symptoms, 
Hopewell-Smith  argues  that  they  should  be  suspected  in  weak  and 
unhealthy  patients,  and  that  such  suspicion  should  contra-indicate 
conservative  operations,  also  that  they  may  explain  certain  difficulties 
of  devitalization  or  anesthetization  of  the  pulp  or  cause  a  related 
change  in  the  pericementum  or  brittleness  in  the  dentin. 

Fig.  385 


Fibroid  degeneration  of  the  pulp:  D,  dentin  with  tubules;  FO,  fibroid  odontoblasts; 
P,  atrophied  pulp  tissue. 


Morbid  Anatomy. — ^"The  odontoblasts  become  sheaved  with  or 
without  fatty  degeneration;  the  arteries,  permanently  distended, 
undergo  hyaline  degeneration;  a  reticular  atrophy  occurs,  with  dis- 
appearance of  cells  and  nuclei  of  both  pulp  and  vessels  and  nerves, 
and,  at  the  same  time,  the  connective-tissue  fibres  undergo  hyper- 
plasia. The  pulp  goes  more  or  less  gradually  through  the  stages 
shown  in  Fig.  383,  finally  producing  the  stage  shown  in  Figs.  384 
and  385,  in  which  the  pulps  are  shrunken  and  may  have  left  the  wall 
of  the  pulp  chamber.     ''Many  areolar  spaces  appear  which  may  be 


424 


DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 


arranged  in  chains.  The  odontoblasts  are  degenerated.  The  pulp 
stroma  is  very  dense,  has  a  clear,  fibrous  structure,  becomes  very 
marked  in  staining,  and  is  highly  differentiated  from  the  surrounding 
tissue.  The  bloodvessels,  nerves,  cells,  and  connective-tissue  have 
all  disappeared,  and  their  place  is  taken  by  a  new,  firm,  fibrous 
structure  devoid  of  cells,  nuclei,  or  any  regular  arrangement  of 
constituent  parts." 

Fig.  386 


Fatty  degeneration  of  the  pulp.  (V.  A.  Latham.) 


"There  is  no  calcification  of  the  pulp  and  no  obliteration  of  the 
dentinal  tubules. 

"The  proximate  cause  and  associate  phenomena  are  not  as  yet 
clearly  related." 

Fatty  Degeneration  of  the  Pulp. — During  the  course  of  degenera- 
tion of  the  elements  of  the  pulp  fatty  changes  may  occur  as  in  other 
parts.  The  fatty  changes  occur  in  the  walls  of  the  arteries  and 
sheaths  of  the  nerves,  and  in  the  odontoblasts.    (Hopewell-Smith.) 

Cloudy  swelling  also  appears.    (Latham.)    (See  Figs.  386  and  387.) 


CHRONIC  INFLAMMATION  OF  THE  PULP 
Fig.  387 


425 


Cloudy  swelling;  parenchj'matous  degeneration;  pulp  nodules.   (V.  A.  Latham.') 

Fig.  388 


Colloid   degeneration   of  the   pulp.      Compare  with  Fig.   29.      (V.  A.   Latham.) 

1  Dr.  Vida  A.  Latham's  illustrations  are  from  her  paper  on  Some  Pathological 
Features  of  the  Pulp,  Journal  of  the  American  Medical  Association,  September  22, 
1906. 


426         DESTRUCTIVE  DISEASES  OF  THE  DENTAL  PULP 

Fig.  389 


Great  thickening  of  nerve  bundle.     From  a  case  of  chronic  neuralgia, 
many  teeth  extracted  for  neuritis.   (V.  A.  Latham.) 

Fig.  390 


Patient  had 


Neoplasm  of  the  pulp.    (V.  A.  Latham.) 


CHRONIC  INFLAMMATION  OF   THE  PULP  427 

Colloid  Degeneration  of  the  Pulp. — The  demonstration  of  colloid 
material  within  the  pulp  has  been  made  by  Latham,  as  shown  in 
Fig.  388.  She  states  that  it  may  become  calcified.  The  condition 
is  very  rare.  Other  degenerations  such  as  Wallerian,  hyaline,  and 
amyloid  have  been  noted.^  It  would  seem  that  the  pulp  may  be 
subject  to  any  form  of  degeneration  seen  elsewhere. 

Nerve-end  Degeneration  of  the  Pulp. — The  degeneration  of  nerves 
occurs  in  the  pulp  as  it  may  in  the  pericementum  and  from  the 
same  causes  that  produce  endarteritis.  The  bundles  may  be  enlarged. 
Neuralgia  may  be  associated  with  it. 

Neoplasm  of  the  Pulp. — Latham  claims  that  a  neoplasm  may  occur 
in  the  pulp,  and  offers  the  photomicrograph  shown  in  Fig.  390  as 
proof  of  the  fact.  I  do  not  know  of  any  cases  in  which  such  a  pulp 
condition  has  been  related  with  a  malignant  growth  outside  of  the 
pulp  cavity,  though  it  may  not  be  impossible. 

Many  of  the  destructive  pulp  diseases  occur  in  the  pulps  of  the 
temporary  teeth,  and  are  to  be  treated  in  like  manner,  except  as  to 
the  use  of  arsenic,  which,  being  accompanied  by  greater  danger, 
should,  for  the  most  part,  be  replaced  by  other  methods  of  pulp 
removal.  This  point  is  discussed  at  length  in  the  chapter  upon 
Removal  of  the  Pulp. 

If  the  tooth  roots  be  largely  resorbed,  the  pulp  may  bear  capping 
even  when  ulceration  has  occurred.  The  pulp  may  die  under  this 
capping,  when  the  case  is  further  treated  as  indicated.  (See  Chronic 
Apical  Abscess.) 

1  Talbot:  Dental  Cosmos,  1909,  p.  1150. 


CHAPTER  XIV. 

METHODS  OF  REMOVAL  OF  THE  DENTAL  PULP 
AND  ROOT-CANAL  FILLING. 

The  removal  of  the  dental  pulp  is  predicated  upon  subsequent 
root  filling.  If  not  done,  an  apical  abscess  probably  will  later  result. 
As  all  root  fillings  are  at  present  scientifically  shown  unreliable  the 
considerations  here  presented  are  tentative  and  in  anticipation  of 
the  hoped  for  discovery  of  better  methods.  There  are  four  general 
methods  by  which  a  patient  or  pulp  may  be  prepared  for  the  opera- 
tion of  pulp  extirpation.    These  are  as  follows: 

1.  Anesthetization  of  the  patient  and  removal  of  the  pulp  during 
the  period  of  anesthesia. 

2.  iVnesthetization  of  the  apical  tissue  by  mucous  local  anesthesia 
or  of  a  main  nerve  branch  (conductive  anesthesia)  and  the  removal 
of  the  pulp. 

3.  Anesthetization  of  the  pulp  by  cocain  or  novocain  (procain),  or 
in  some  cases  by  ner^'ocidin,  or  by  freezing  and  the  remo^'al  of  the 
pulp. 

4.  Devitalization  of  the  pulp  followed  by  its  removal. 

1.  General  Anesthesia. — The  pulp  of  a  single-rooted  tooth  may  be 
readily  extirpated  while  the  patient  is  anesthetized  by  nitrous  oxid, 
nitrous  oxid  and  oxygen,  or  by  somnoform.  The  instruments  should 
be  in  readiness,  the  patient  anesthetized,  the  pulp  uncovered  by 
an  engine  bur,  and  the  pulp  extirpated  with  a  barbed  broach  or 
Donaldson  cleanser. 

In  cases  of  multirooted  teeth  the  available  anesthetics  are  ether, 
which  is  rarely  used  for  the  purpose,  and  nitrous  oxid  and  oxygen 
administered  by  nasal  inhalation;  a  true  anesthesia  is  required  as 
distinguished  from  analgesia  described  on  page  312. 

The  ordinary  nitrous  oxid  outfit  is,  however,  of  value  by  enabling 
the  operator  to  remove  the  diseased  bulb  of  the  pulp  of  a  multirooted 
tooth,  after  which  and  while  the  patient  is  conscious  other  methods 
of  removal  of  the  radicular  portions  of  the  pulp  may  be  employed. 
(See  page  404.) 

2.  Anesthesia  of  the  Conductive  Apparatus. — ^The  second  general 
principle  consists  in  the  use  of  mucous,  diploic  or  conductive  anes- 
thesia to  block  the  transmission  through  the  fifth  nerve  leading  from 

(428) 


ANESTHESIA  OF  THE  PULP  429 

the  part.  This  has  been  previously  described  for  hypersensitive 
dentin  (see  page  314).  Sometimes  in  conducti^T  anesthesia  it  fails 
for  the  pulp  while  other  tissues  seem  anesthetized  (Blum)  or  the  apical 
portion  of  the  pulp  may  be  sensitive  (Reithmiiller)  a  condition  difficult 
of  explanation,  except  on  the  ground  that  some  nerve  tracts  or  fila- 
ments are  not  affected.  Otherwise  the  pulp  may  be  painlessl\' 
removed.  The  success  of  mucous  and  diploic  anesthesia  depends 
upon  infiltration  of  the  apical  tissue.  These  methods  are  very  valu- 
able in  all  cases  of  difficulty  with  diseased  pulps  and  indeed  are  choice 
methods  in  any  pulp  removal.  The  objections  are  that  extirpation 
may  not  be  complete  owing  to  the  insensitivity,  or  that  one  may  even 
operate  on  apical  tissue,  producing  pericementitis.  The  use  of  phenol 
may  obviate  the  first  difficulty.  Claims  have  been  made  for  a  slight 
sidewise  blow  struck  upon  the  tooth  to  paralyze  the  pulp  nerves  by  a 
stretching  shock. 

3.  Anesthesia  of  the  Pulp.- — For  this  purpose  cocain  hydrochlorid 
or  novocam  are  generally  employed.  There  are  three  practical 
methods  by  which  it  may  be  introduced  into  a  pulp : 

Pressure  Anesthesia. — By  pressure  accomplished  by  means  of  raw 
vulcanite.  A  strong  solution  (50  per  cent,  to  saturated  solution)  of 
cocain  hydrochlorid  or  novocain  is  made  in  water,  or  preferably  in 
some  mild  antiseptic  solution  which  does  not  cloud  on  admixture  (as 
Borine)  in  order  to  avoid  infection  of  pulp  or  apical  tissue.  A  small 
piece  of  amadou  (spunk)  or  cotton  is  saturated  with  it  and  laid  upon 
the  orifice  of  exposure.  The  cavity  is  filled  with  the  rubber,  a  flat 
strip  being  fed  first  into  the  cervix  and  later  folded  into  the  cavity. 
This  confines  the  solution  better,  and  upon  this  is  placed  a  flat-ended 
plugger  or  burnisher  broad  enough  to  concentrate  the  force  upon  the 
cotton.  A  broad  piece  of  cotton  placed  over  the  rubber  is  sometimes 
of  assistance  in  preventing  slipping.  Gentle  pressure  is  now  made 
and  a  slight  pain  is  usually  felt.  The  pressure  should  be  maintained 
until  this  passes  away,  then  it  is  increased  little  by  little  until  some 
force  is  exerted.  The  rubber  and  cotton  are  then  removed,  the  pulp 
cavity  opened,  the  progress  of  the  anesthesia  tested  with  a  fine  broach 
and  the  pulp  lifted  away.  Some  prefer  to  place  a  prepared  billet  of 
cocain  or  novocain  upon  the  pulp,  others  prefer  chloroform,  eugenol  or 
alcohol  as  the  solvent.    Novocain  is  understood  as  equal  to  cocain. 

For  multirooted  teeth  the  pressure  should  be  prolonged,  and  to 
prevent  return  of  sensation  and  hemorrhage  while  extirpating  it  is 
well  to  instil  carbolic  acid  into  the  pulp  tissue  by  means  of  a  fine, 
smooth  broach. 

In  some  cases  the  operation  fails  because  the  direction  of  the 
pressure  has  been  away  from  the  pulp  or  because  the  cotton  has 


430     REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL  FILLING 

slipped  from  its  place.  Sometimes  the  orifice  of  exposure  may  be 
enlarged,  but  as  sensation  is  discovered  a  fresh  application  must  be 
made.  In  cases  with  large  foramina  the  application  may  fail;  with 
the  incomplete  foramen  of  moderate  size  it  is  more  successful. 

Sometimes  repeated  applications  fail  to  effect,  though  the  appli- 
cation is  not  painful,  and  at  times  the  pressure  is  not  tolerated  at 
all,  owing  to  the  irritability  of  the  pulp,  due  to  continued  hyperemia 
or  inflammation.  Even  six  or  eight  applications  have  at  times 
failed  even  when  a  fair  and  accessible  exposure  existed.  Sedation 
for  a  day  or  two  sometimes  permits  a  successful  application.  This 
action  of  cocain  corresponds  to  that  in  inflamed  tissue.  Sometimes, 
even  when  the  cotton  enters  the  pulp  tissue,  the  pulp  is  still  sensitive 
higher  up.  In  such  a  case  I  have  often  packed  devitalizing  fiber 
into  the  pulp  in  place  of  the  cotton  and  without  further  pain.  In 
cases  of  cavities  without  walls  to  confine  the  rubber,  it  is  well  to 
enclose  the  buccal  and  lingual  embrasures  with  the  thumb  and 
forefinger.  In  very  broad  occlusal  cavities  the  finger-tip  confines 
the  rubber  nicely. 

When  only  canal  filaments  are  present,  any  septic  matter  present 
should  be  removed  by  syringing  repeatedly  with  an  antiseptic  solu- 
tion, or  better  formocresol  1  part,  eugenol  5  to  7  parts  applied  for  a 
day  or  two;  then  the  canals  should  be  thoroughly  dried,  and  the  cocain 
dissolved  in  an  antiseptic,  is  carried  on  a  cotton  thread  into  the  canals 
and  against  the  pulp  remnant.  A  small  piece  of  rubber  is  placed  in 
one  canal  and  the  pressure  confined  to  that  canal  by  means  of  a 
plugger  which  will  about  fill  the  canal.  The  action  is  then  repeated 
in  the  other  canals.  This  produces  better  results  than  a  general 
pressure  over  all  the  canals  at  once. 

If  used  after  arsenic  has  been  applied  the  results  are  not  usually  so 
good,  but  sometimes  the  method  is  successful.  To  avoid  the  intro- 
duction of  arsenic  into  apical  tissue  all  sloughing  portions  should  be 
removed  and  all  arsenic  washed  out. 

When  the  pulp  is  not  exposed,  the  application  to  the  dentin  over 
the  pulp  permits  advance,  a  pocket  being  created  in  the  dentin  with 
a  bur,  which  aids  the  further  instillation  of  the  cocain;  finally,  the 
pulp  is  exposed  and  the  anesthesia  is  completed. 

Clyde  Davis  recommends  for  the  purpose  of  producing  the  exposure 
the  use  of  a  drop  of  1  to  1000  adrenalin  chlorid  followed  by  a  drop  of 
37  per  cent,  formaldehyd,  then  pressure  with  raw  vulcanite. 

Where  calcific  formations  are  present  they  present  some  difficulty, 
though  with  persistence  one  may  be  enabled  to  anesthetize  the  pulp. 
Custer  recommends  75°  to  90°  sulphuric  acid  to  aid  in  loosening 
the  nodule.      Cook  recommended  an  application  of  10  per  cent. 


ANESTHESIA  OF  THE  PULP  431 

sulphuric  acid  for  a  few  minutes,  followed  by  sodium  bicarbonate 
previous  to  a  reapplication  of  the  pressure  anesthesia,  as  highly 
effective  in  aiding  penetration  of  the  cocain.  Desiccation  is  always 
a  valuable  preliminary,  aiding  penetration.  Claims  are  made  for 
eucain,  or  alcohol  for  producing  pulp  anesthesia  by  pressure. 

There  is  a  possibility  of  the  introduction  of  cocain  into  the  general 
circulation,  and  some  systemic  effect  may  be  noted,  though  often 
this  will  be  due  to  the  agitation  of  the  patient.  Some  patients  have 
complained  of  tingling  in  the  fingers.  If  syncope  be  threatened 
aromatic  spirit  of  ammonia  should  be  administered,  the  head  lowered, 
the  feet  elevated,  and  smelling  salts  or  amyl  nitrite  applied  to  the 
nostrils.  It  is  always  well  to  administer  aromatic  spirit  of  ammonia 
or  camphorated  validol  before  using  cocain  for  any  purpose.  In  some 
cases  of  fracture  exposing  the  pulp  a  crystal  of  cocain  laid  against 
the  pulp  has  caused  anesthesia  by  mere  absorption;  if  this  fails  it  ■u'ill 
at  least  prepare  for  pressure  anesthesia. 

Hemorrhage  following  the  extirpation  of  the  pulp  is  sometimes 
copious.  To  avoid  this,  carbolic  acid  should  be  instilled  into  the 
pulp  tissue  by  means  of  a  smooth  broach.  A  fine  Donaldson  cleanser 
may  be  passed  to  the  apex  of  the  canal  and  slowly  twisted,  the  oper- 
ation consuming  several  minutes,  ^his  torsion  of  the  pulp  largely 
limits  the  hemorrhage.  If  it  occur  it  should  be  allowed  to  check 
itself,  though  if  desired  a  trifle  of  a  mixture  of  powdered  alum  and 
powdered  thjTuol  may  be  taken  upon  cotton  wet  with  phenol- 
camphor  and  passed  to  the  end  of  the  canal.  Deliquesced  zinc  chlorid 
checks  hemorrhage  promptly;  a  dilution  is  less  painful. 

It  is  an  open  question  whether  canals  from  which  living  pulps 
have  been  removed  should  be  filled  immediately  or  not.  There  is 
liable  to  be  a  secondary  hemorrhage,  particularly  when  adrenalin 
is  used  with  the  cocain.  j\Iany  prefer  to  fill  at  once,  claiming  that 
surgical  pericementitis  is  the  only  result.  Ottolengui  has  suggested 
the  use  of  dry  cotton  to  absorb  any  blood.  If  this  is  bichloridized  or 
otherwise  antisepticized  it  is  better.  The  \\Titer  as  a  rule  places  phenol 
camphor  plus  menthol  on  cotton  as  a  sedative  antiseptic.  This,  as  a 
rule,  permits  the  healing  of  the  parts  without  much  tenderness,  and 
really  consumes  but  little  more  time  in  the  aggregate.  It  seems  best 
to  a^'oid  formaldehyd  in  this  connection,  though  the  writer  in  this 
yields  to  the  general  sentiment  rather  than  from  much  fear  of  modified 
formocresol.    Still  there  is  nothing  gained  by  irritating  normal  tissue. 

High  Pressure  Anesthesia. — ^\Yhen  considerable  dentin  o^'e^lies  the 
pulp,  or  when  a  tooth  is  sound,  the  most  expeditious  method  of  pulp 
anesthesia  is  the  introduction  of  a  2  per  cent,  solution  of  cocain  or 
novocain  by  means  of  the  compound  sjTinge.     This  consists  of  a 


432     REMOVAL  OF  DENTAL  PULP  AND  ROOT-CANAL    FILLING 

strong  metal  s\Tinge,  the  piston  of  which  is  actuated  by  means  of 
levers  which  multiply  the  power  of  the  hand.  The  Myers-  syringe  is 
one  of  the  best,  though  several  forms  are  obtainable  (see  Fig.  322). 
The  S}Tinge  nozzle  is  embedded  in  a  small  hole  drilled  in  the  dentin  by 
one  of  two  methods :  The  hole  may  be  made  small  with  parallel  sides, 
as  when  drilled  with  a  Xo.  |  bur;  the  sjT-inge  nozzle  has  then  slightly 
conical  sides  at  the  point,  intended  to  jam  a  fit  when  introduced  with 
force  into  the  drill  pit.  In  the  other  method  the  drill  pit  is  made 
with  a  cone-pointed  bur  or  bud  bur,  and  the  syringe  point  is  made 
flat-ended,  a  form  easy  to  maintain  upon  the  point.  All  air  must 
be  expelled  from  the  syringe.  It  is  wise  also  to  expel  all  air  from 
the  drill  pit  by  a  slight  pressure  while  the  syringe  point  is  loosely 
held  in  the  pit.  Then  a  rotary  motion  under  forward  pressure 
embeds  the  point. 

If  no  leakage  occurs  the  force  of  the  piston  drives  the  anesthetic 
through  the  fibrils  in  the  tubules  and  into  the  pulp.  The  pressure 
must  be  maintained  for  about  three  minutes,  though  several  applica- 
tions may  be  made  each  time  drilling  into  the  point  of  sensation.  The 
anesthesia  is  then  tested  by  drilling  with  a  No.  h  bur  in  the  direction 
of  the  pulp.  If  the  dentin  be  sensitive  the  syringe  is  to  be  reapplied. 
Often  the  bur  sinks  into  a  sensitive  pulp  without  warning  by  dentinal 
sensitivity.  In  such  case  the  syringe  is  reapplied  for  a  moment,  when, 
as  a  rule,  the  anesthesia  will  be  complete.  In  all  cases  when  testing 
the  drill  hole  should  not  be  enlarged,  as  this  prevents  reapplication. 
Too  much  cocain  should  not  be  introduced,  as  it  has  happened  that 
the  area  about  the  apical  tissue  has  been  profoundly  injected,  with, 
of  course,  possibility  of  systemic  complication.  This  warning 
applies  to  the  second  application  rather  than  the  first.  Novocain  is 
less  dangerous.  When  desirable,  the  enamel  of  a  sound  tooth  which  is 
to  be  crowned  may  be  ground  away  until  the  dentin  is  reached,  or 
if  enamel  must  be  removed  in  only  limited  degree,  as  for  a  tap  upon 
the  lingual  side  of  an  incisor  or  in  the  fissure  of  a  bicuspid,  a  "spot" 
is  first  made  with  a  dentate  bur,  then  a  spear  drill  is  driven  through 
the  enamel  only  just  reaching  the  dentin.  The  drill  hole  is  then 
enlarged  as  widely  as  permissible,  after  which  the  pit  is  made  in  the 
dentin  with  a  No.  |  bur. 

The  lingual  side  of  upper  incisors  will  permit  of  sufficiently  direct 
pressure  to  enable  the  operator  to  center  the  syringe  point,  but  in 
many  cases  in  which  crowns  are  indicated  the  labial  side  may  be 
used  with  advantage,  especially  at  the  neck  when  the  cementum  is 
exposed.  Later,  the  entrance  tap  is  made  in  line  with  the  pulp  axis 
and  the  first  opening  closed  with  cement  (finally  with  silicate  if  crown- 
ing is  not  intended).    The  occlusal  surfaces  or  parts  of  cavities  may 


ANESTHESIA  OF  THE  PULP  433 

be  used  in  upper  posterior  teeth.  The  labial  or  mesiobuccal  side  must 
always  be  used  in  the  lower  teeth,  unless  a  cavity  be  used,  sometimes 
preferably  at  the  neck,  sometimes  higher  up.  In  cavities  having  suffi- 
cient dentin  over  the  pulp  the  pit  may  be  made  in  the  pulpal  wall,  and 
if  for  any  reason  it  is  needed  the  drill  pit  may  begin  at  the  cervical 
portion  of  the  cavity  and  extended  mto  the  root  dentin  and  parallel 
with  the  pulp.  The  pit  must  be  deeper  than  the  syringe  point  will 
penetrate,  so  that  the  pressure  may  force  the  solution  laterally  through 
the  tubules,  which  are  at  a  right  angle  to  the  axis  of  the  pulp  and  the 
pit.  There  are  occasional  failures  with  this  method.  I  recall  a  lower 
molar  sound  but  the  pulp  h\'peremic.  Drilling,  at  first  intended  to 
reach  the  dentin  only,  was  carried  to  the  pulp  without  pain.  Anes- 
thesia was  begun  with  confidence  but  abandoned  after  an  hour  of 
trials  including  ordinary  pressure  anesthesia.  Arsenic  was  completely 
successful.  In  some  cases  solutions  of  antiseptics  have  been  as  effec- 
tive with  this  instrument  as  the  cocain  solution.  The  experiment 
may  not  be  successful. 

According  to  Brouardel,^  of  Paris,  the  effects  of  cocain  are  acute 
and  chronic.  The  former  develop  usually  in  ten  or  fifteen  minutes, 
or  even  up  to  three-quarters  of  an  hour  after  the  injection.  They  are: 
precordial  anxiety,  filiform  and  extra  rapid  pulse,  lividity  of  the  face, 
coldness  in  the  extremities,  and  abundant  perspiration;  rise  in  tem- 
perature, irregular  respiration,  tingling  sensations  in_the  hands, 
blunted  tactile  sensibility,  excitement,  loquacity,  weeping,  anger  or 
hysterical  fits;  bilious  vomiting  with  or  without  diarrhea,  anuria, 
symptomatic  epilepsy,  followed  by  motor  and  sensory  paralysis. 
Death  occurs  in  from  two  minutes  to  five  hours  after  administration, 
though  in  the  chronic  cases  fatality  usually  does  not  result. 

Placing  the  patient  in  the  horizontal  position,  giving  inhalations 
of  amyl  nitrite,  and,  if  further  cardiac  stimulation  be  necessary,  hj-po- 
dermic  injections  of  ether  or  strychnin  are  indicated.  Strong  coft'ee  is 
to  be  administered  before  dismissal  in  any  untoward  case  and  giving 
30  minims  of  aromatic  spirit  of  ammonia  or  6  drops  of  camphorated 
validol  in  a  little  water  previous  to  operation  is  a  wise  precaution  even 
with  novocain. 

The  chronic  poisoning  occurs  mostly  in  those  addicted  to  its  use. 
Some  develop  a  tolerance  of  the  drug,  withstanding  from  30  to  120 
grains.  Tachycardia  and  intense  psychic  disturbances,  leading  to 
physical  and  mental  collapse,  are  observed. 

Cataphoresis. — ^The  third  and  least  desirable  form  of  cocain  anes- 
thesia of  the  pulp  consists  of  its  introduction  by  the  cataphoric  cur- 

1  Dental  Cosmos,  1905,  p.  1508. 
28 


434      REMOVAL  OF  DENTAL  PULP  AND  ROOT-CANAL  FILLING 

rent.  (An  ionization  apparatus  is  similar  and  can  be  used,  see  p.  327.) 
It  has  the  disadvantage  of  consuming  more  time,  but  may  serve  when 
patients  are  timid.  A  10  per  cent,  solution  of  cocain  hydrochlorid 
is  applied  to  the  pulpal  wall  of  the  cavity,  the  tooth  being  previously 
placed  under  rubber  dam.  The  anode  of  the  cataphoric  outfit  is 
applied  to  the  cotton  and  the  cathode  placed  in  the  hand  or  at  the 
cheek. 

The  dentin  may  be  anesthetized  as  well;  fifteen  minutes  or  more 
may  be  required  to  get  an  exposure.  If  desired,  this  method  may  be 
used  to  obtain  a  pulp  exposure  and  the  pressure  method  employed  to 
complete  the  operation. 

When  beginning  with  an  exposed  pulp,  about  fifteen  minutes  will 
be  required  unless  hyperemia  of  the  pulp  exists,  when  a  longer  time 
will  be  needed.  As  with  the  pressure  method,  there  may  be  occa- 
sional failures.  It  will  be  noted  that  there  is  advantage  in  time  and 
convenience  in  the  pressure  and  blocking  methods. 

Carbolic  Acid. — The  fourth  method  of  producing  pressure  anes- 
thesia consists  in  the  use  of  carbolic  acid  in  place  of  the  cocain,  or  in 
case  of  obstinate  canal  filaments  of  a  solution  of  cocain  in  carbolic 
acid  on  cotton  packed  against  the  pulp  filaments.  The  method  is  as 
in  ordinary  pressure  anesthesia.  While  an  anesthetic  it  probably 
acts  by  devitalizing  protoplasm  through  coagulation  of  albumin. 
(See  p.  410.) 

Nervocidin. — The  fifth  method  of  producing  pulpal  anesthesia  is 
by  the  application  of  nervocidin,  an  alkaloid  obtained  by  D.  Dalma 
from  the  East  Indian  plant  gasu-hasu.  Arkovy  recommended  that  a 
portion  be  applied  to  the  exposed  pulp  for  twenty-four  hours,  when 
it  may  be  removed  painlessly.  Soderberg^  suggests  the  addition  of 
a  small  amount  of  cocain  hydrochlorid  to  overcome  the  primary 
irritating  effect  of  the  nervocidin.  If  dentin  be  over  the  pulp,  an 
additional  application  of  twenty-four  hours'  duration  is  required  to 
obtain  an  exposure.     (See  p.  326.) 

Freezing. — Sprays  of  rapidly  vaporizable  substances^  such  as  ethyl 
or  methyl  chlorid,  directed  against  the  exposed  pulp,  the  tooth  being 
isolated  under  rubber  dam,  will,  in  some  cases,  render  the  pulp  entirely 
insensitive,  although,  as  a  rule,  they  fail  to  entirely  anesthetize  to 
the  apical  foramen.  Ice  is  formed  which  acts  as  a  non-conductor. 
The  method  is  painful  and  not  applicable  in  many  cases  of  highly 
irritable  pulps.  (See  p.  325.)  Ottolengui  has  suggested  several 
applications  of  ether  on  cotton  to  slowly  refrigerate  the  pulp  bulb 
and  finally  leaving  the  cotton  while  the  first  spraying  with  ethyl 
chlorid  is  done. 

»  Dental  Cosroog,  1901  and  1903, 


DEVITALIZATION  OF  THE  PULP  435 

4.  Devitalization  of  the  Pulp. — Devitalization  of  the  pulp  by  the 
use  of  arsenic  trioxid  as  a  preliminary  to  its  successful  removal 
is  the  oldest  of  the  methods  employed  at  the  present  day/  and 
as  shown,  it  still  has  to  be  resorted  to  either  from  necessity  or 
convenience. 

The  method  has  its  value  in  the  very  teeth  in  which  its  use  is  least 
objectionable,  namely,  the  posterior  teeth.  There  is  no  danger  of 
the  use  of  arsenic  in  teeth  having  completed  roots,  or  in  unresorbed 
temporary  teeth,  provided  the  arsenic  be  accurately  sealed  in  the 
cavity  so  that  it  does  not  escape  upon  the  gum.  If  it  does  escape  it 
may  destroy  the  gum  or  pericementum  and  cause  partial  necrosis  of 
bone  or  the  complete  loss  of  the  tooth  together  with  some  bone.  The 
pulp  always  dies  through  a  process  of  venous  hj^eremia  induced  by 
the  protoplasmic  irritant  and  poison.  Some  of  this  is  absorbed  by 
the  pulp.  This  hyperemia  is  progressive  from  the  pulp  bulb  toward 
the  apex  of  the  root,  and  there  it  causes  the  death  of  the  apical  portion 
of  pulp  through  interference  w^ith  its  nutrition.  Sometimes  this 
hyperemia  of  the  pulp  extends  into  the  apical  tissue,  but  if  the  pulp 
be  left  in  situ,  necrosis  of  apical  tissue  never  results,  but,  on  the 
contrary,  the  hyperemia  becomes  resolved  after  the  death  of  the 
pulp. 

The  writer  fails  to  see  wherein  such  a  hyperemia  differs  in  conse- 
quence from  that  produced  by  the  surgical  removal  of  a  pulp  and 
denominated  with  favor  as  surgical  pericementitis.  In  his  hands 
such  teeth  have  given  quite  as  good  results  as  when  other  methods 
have  been  employed.  By  this  it  is  not  meant  that  there  has  been 
no  difficulty  in  devitalizing  some  pulps,  particularly  some  of  those 
in  which  repeated  applications  of  cocain  under  pressure  failed  to 
anesthetize,  but  that  when  carefully  handled  and  sufficient  time  for 
pulp  death  has  been  allowed,  careful  filling  of  the  canal  has  been 
successful. 

There  have  been  assertions  made  that  a  condition  favoring  apical 
granuloma  results  from  the  use  of  arsenic,  but  w^hen  the  collateral 
lack  of  asepsis,  leaving  of  pulp  tissue,  poor  root  filling,  etc.,  is  taken 
into  consideration,  this  is  not  a  result  proved  against  the  arsenic. 
Indeed  the  indictment  against  all  root  fillings  as  not  mechanically 
perfect  may  explain  this  result.     (See  page  467.) 

Action  of  Arsenic  upon  the  Pulp.- — Arkovy^  was  the  first  to  point 
out  the  details  of  the  action  of  arsenic  upon  the  dental  tissues : 

"1.  AS2O3  brought  into  contact  with  the  tooth  pulp  acts  in  the 
following  way :    A  certain  degree  of  inflammatory  hyperemia,  total  or 

1  Introduced  by  Spooner  in  1836. 

-  Transactions  of  the  International  Medical  Congress,  London,  1881. 


436     REMOVAL  OF  DENTAL  PULP  AND  ROOT-CANAL  FILLING 

partial,  depending  upon  the  quantity  of  the  agent  appHed,  sets  in; 
the  bloodvessels  become  expanded,  and  here  have  a  tendency  to 
thrombosis.  This  latter  effect  may  also  be  in  connection  with 
embolism  of  the  capillaries,  when  the  agent  is  quickly. taken  up  into 
the  bloodvessels. 

"2.  AS2O3  produces  no  coagulation  of  tissue  whatever. 

"  3.  It  has  a  specific  influence  upon  the  blood  corpuscles,  combining 
vvdth  the  hemoglobin  to  form  a  compound  of  arsen-hemoglobin,  and 
of  this  chemical  process  there  seems  to  be  evidence  in  the  profuse 
yellowish  tinge  of  the  whole  pulp  tissue  and  in  the  discoloration  of 
blood  in  several  of  the  bloodvessels. 

"4.  In  nearly  every  case  it  is  taken  up  in  substantia  (in  form  of 
molecules)  into  the  blood-ways;  when  there  it  produces  besides  the 
above-mentioned  changes,  granular  detritus  of  the  contents  and 
anemic  collapse — shrinkage,  the  latter  effect  being  brought  about 
nearly  exclusively  in  cases  where  greater  doses  were  used. 

"  5.  The  bulk  of  the  pulp  tissue — viz.,  connective-tissue  fibers  and 
odontoblasts — undergoes  no  change  whatever;  not  so  the  connective 
tissue  cells,  which  increase  three  or  four  times  their  normal  size. 

"6.  The  special  action  of  arsenic  trioxid  upon  the  nerve  element 
consists  in  the  following :  the  neurilemma  is  only  so  far  influenced 
that  its  nuclei  are  somewhat  increased;  a  more  essential  change  takes 
place  in  the  axial  part,  where,  after  the  application  of  more  than 
1  mg.,  granular  destruction  of  myelin  sets  in,  and  the  axis-cylinder 
commences  here  and  there  to  disappear.  A  very  surprising  alteration 
may  be  seen  in  the  notchy  tumefaction  of  the  axis-cylinder,  described 
heretofore  almost  only  in  cases  of  central  lesions. 

"  7.  All  these  alterations  occur  in  and  among  normal-looking  tissue. 

"8.  The  action  of  arsenic  trioxid  is  macroscopically  exhibited  by 
a  brownish-red  tinging  of  the  whole  or  of  certain  parts  of  the  pulp 
body,  as  well  as  of  the  neighboring  dentin  and  the  cementum,  this 
latter  in  cases  treated  with  greater  doses — viz.,  2  to  5  mg.  This 
alteration  is  most  expressed  at  the  top  of  the  crown  pulp  and  at 
the  apical  one-fourth  to  one-third  part.  This  circumstance  may 
be  considered  as  an  external  evidence  of  the  devitalization  being 
completely  attained  to." 

Miller's  experiments^  upon  the  tails  of  mice  (made  without  and 
with  rings  at  the  root  of  the  tail  to  simulate  the  surrounding  of  the 
apical  vessels  of  a  tooth;  made  without  and  with  encasement  of  the 
tails  in  plaster  of  Paris  to  imitate  the  rigid  surroundings  of  the  dental 
pulp)  showed  that  in  the  absence  of  the  plaster  encasement  enormous 

1  Dental  Cosmos,  1894. 


DEVITALIZATION  OF  THE  PULP  437 

edema  of  the  tail  was  produced  and  a  sensory  paralysis  of  the  hind 
limbs;  complete  anesthesia  of  the  tail  occurred  in  forty-eight  hours. 
"  The  action  of  arsenic  appeared  somewhat  accelerated  when  a  glass 
ring  was  applied  close  to  the  root  of  the  tail.  In  more  than  forty  cases 
there  was  not  one  in  which  the  action  of  the  arsenic  extended  beyond 
the  ring,  and  the  action  was  not  appreciably  affected  by  enclosing  the 
tails  in  plaster  casts.  The  action  of  the  arsenic  is  of  a  progressive 
nature,  beginning  at  the  point  of  application  and  extending  gradually 
in  each  direction." 

Flagg^  devitalized  ten  pulps  and  removed  them,  cut  off  the  portion 
of  the  bulb  of  each  which  had  contact  with  the  arsenic,  and  tested  the 
ten  pulps  together  by  Reinsch's  test.  Arsenic  was  found,  estimated 
at  a  one-hundred-thousandth  part  of  a  grain,  or  one-millionth  of  a 
grain  for  each  pulp.  Prinz  has  later  confirmed  this.  Allowing  for 
possible  mechanical  introduction  or  contact  of  arsenic  during  extirpa- 
tion, the  quantity  of  arsenic  introduced  by  the  circulation  must  be 
very  minute  indeed. 

Flagg  argued  that  as  the  pulp  subsequently  putrefies  it  cannot 
have  died  as  the  result  of  arsenical  poisoning  alone. 

In  the  roots  with  large  foramina  arsenic  may  be  absorbed,  as  areas 
of  devitalization  of  the  apical  and  overlying  gum  tissue  have  been 
noted.  In  several  apparently  authentic  cases  the  pericementum  of 
a  mature  tooth  has  been  said  to  be  destroyed  from  the  apex  down 
and  the  tooth  lost.  I  have  never  seen  such  a  case  resulting  from  the 
arsenical  method  alone  in  either  clinical  or  private  practice,  although 
cases  of  marginal  gum,  alveolar,  and  pericemental  death,  beginning 
as  the  result  of  leakage  or  application  to  perforations,  have  been 
noted.  It  is  probable  that  as  stasis  proceeds  the  apical  portion  of 
the  pulp  becomes  involved  in  advance  of  arsenic  absorption.  Miller's 
experiments  show  that  arsenic  does  not  pass  the  point  of  constriction. 

Variations  in  the  Action  of  Arsenic. — In  most  cases  of  fully  formed, 
single-rooted  teeth  in  young  adults  an  application  of  arsenical  paste 
directly  to  the  exposed  pulp  will  be  followed  by  the  complete  death 
of  the  organ  in  forty-eight  hours.  At  the  expiration  of  that  time  a 
sterilized  broach  may  be  passed  almost  to  the  apex  of  the  root  and 
the  pulp  removed  en  masse  without  pain.  Pulps  of  molars  require  a 
longer  time,  often  a  week,  before  the  filaments  are  dead.  The  finer 
filaments  resist  longer  than  the  larger  ones.  If  pulp  nodules  exist, 
the  action  of  the  arsenic  may  be  delayed  or  in  some  cases  be  almost 
nil.  In  calcareous  and  other  chronic  pulp  degenerations  the  action 
is  also  delayed.     If  arsenical  applications  are  made  over  a  layer  of 

1  Dental  Cosmos,  1868. 


438     REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL  FILLING 

dentin,  the  same  delay  is  noted,  and  is  increased  in  very  dense 
teeth.    There  is  also  a  greater  tendency  to  suffusion. 

Some  pulp,  irrespective  of  the  pulp  condition,  exhibits  a  peculiar 
idiosyncrasy  in  resisting  the  action  of  arsenic,  requiring  large  doses 
and  long  applications  before  succumbing.  Second  applications  often 
require  more  time  to  kill  the  balance  of  the  pulp  than  the  first  appli- 
cation would  have  required.  The  time  used  in  investigation  is 
practically  lost.  The  editor,  therefore,  allows  plenty  of  time;  about 
ten  days  for  molars,  five  for  single-rooted  teeth,  and  prefers  to  find 
the  pulp  entirely  dead. 

The  rational  objections  to  arsenic,  aside  from  its  escape  upon  the 
gum,  are:  (1)  The  possible  production  of  pain.  (2)  Possible  suffu- 
sion of  the  tooth.     (3)  The  time  required. 

The  production  of  pain  may  largely  be  obviated  by  observance  of 
certain  technique.  The  pulp  should  ordinarily  be  exposed  and  be 
slightly  bled  to  relieve  any  hyperemia  or  inflammatory  engorgement 
present,  as  this  seems  to  prevent  the  absorption  of  the  arsenic,  A 
powerful  sedative,  such  as  thymol,  menthol,  cocain  hydrochlorid 
or  morphin  acetate,  should  be  employed  as  a  corrective,  and  the 
menstruum  should  be  sedative  rather  than  coagulant.  All  pressure 
on  the  pulp  should  be  avoided  as  this  produces  pain. 

Prinz  has  suggested  the  rational  improvement  of  using  a  con- 
centrated solution  of  cocain  or  novocain  before  applying  arsenic. 
This  renders  its  primary  action  less  painful  or  painless.^  This  is 
practically  done  when  one  obtains  a  partial  anesthesia  only  when 
pressure  anesthesia  is  tried  and  abandoned  for  arsenic  (see  p.  430). 

Sufficient  time  for  complete  death  should  be  allowed.  If, 
upon  examination  with  a  fine  smooth  broach,  vitality  be  dis- 
covered, a  sedative  should  be  applied  and  pulp  death  awaited. 
Leaving  the  dead  portion  against  the  vital  part  of  the  pulp  is 
even  better  than  making  a  second  application,  as  its  removal  re- 
lieves the  congestion  by  opening  the  vessels,  and  the  congestion  is 
necessary  to  the  end  in  view.  If  the  pulp  give  but  little  response 
upon  probmg  it  may  be  removed.  Plunging  a  bur  into  the  pulp 
cavity  sometimes  produces  a  slight  pain  probably  referable  to  impact 
upon  liquid  pressure  being  felt  at  the  apex  as  there  may  be  no  further 
pain.  In  some  cases  a  still  vital  filament  is  the  explanation.  Some- 
times the  diapedesis  of  red  corpuscles,  associated  with  the  venous 
hyperemia,  causes  a  staining  of  the  pulp  and  dentinal  fibrils  with  the 
liberated  hemoglobin  (see  p.  393).  This  is  unfortunate,  but  can  be 
treated  by  bleaching  with  25  per  cent,  ethereal  pyrozone  sealed  in 

'  Dental  Materia  Medica  and  Therapeutics. 


DEVITALIZATION  OF'  THE  PULP  439 

the  pulp  cavity  for  about  twenty-four  hours  after  the  pulp  is  removed 
and  the  canal  partly  filled.  The  third  objection,  the  matter  of  time, 
does  not  apply  to  the  cases  of  prompt  devitalization,  as  the  time  spent 
in  pulpal  anesthesia  and  checking  hemorrhage  is  in  the  aggregate  no 
less  than  in  the  arsenical  cases.  In  the  delayed  action  of  arsenic  the 
objection  is  valid,  but  the  mucous,  diploic,  conductive  and  general 
anesthesia  methods  are  still  open  to  trial.  The  arsenical  method,  of 
course,  requires  a  longer  waiting  period.  Pulpal  anesthesia  can  be 
tried  when  arsenic  does  not  act  well,  but  should  be  avoided  wh^n  it 
originally  failed.  It  is  not  apt  to  succeed.  As  stated,  these  considera- 
tions apply  mainly  to  posterior  teeth. 

Forms  in  Which  Used. — The  following  is  an  excellent  formula  for 
arsenical  paste : 

IJ — Arsenici  trioxidi       .       '. gr.  xv 

Cocainse  hydrochloridi gr.  xx 

Thymolis  (vel  mentholis) gr.  v 

Olei  carj^ophylli q.  s.  ft.  pasta — M. 

This  should  be  finely  ground  in  a  mortar  and  spread  over  the  bottom  of  a  wide  glass 
jar  so  that  some  of  the  paste  may  be  taken  up  from  the  bottom.  The  arsenic  settles 
to  the  bottom. 

Buckley  recommends  the  following  formula: 

I^ — Arsenic  trioxid gr.  clxxx 

Cocain  alkaloid gr.  xxx 

Thsonol •      .      . gr.  XV 

Petronal TTlxv — M. 

Either  of  the  above  may  have  the  powdered  ingredients  mixed. 
The  cotton  pellet  may  be  wet  with  the  menstruum  and  then  dipped 
into  the  powder.  Lamp  black  added  to  the  paste  colors  it  so  that  it 
is  easily  distinguishable  in  a  cavity.     (Buckley.) 

The  following  are  other  formulae:  The  analgesics  included  are 
intended  to  dilute  the  arsenic  and  quiet  the  pulp,  and  thus  both 
directly  and  indirectly  modify  the  pain. 

IJ — ^Acidi  arsenosi, 

Morphinse  sulph aa  gr.  x 

Acidi  carbolici q.  s.  ft.  pasta — M . 

(J.  D.  White.) 

I^ — ^Acidi  arsenosi gr.  x 

Morphinse  acetatis gr.  xx 

Olei  caryophylli q.  s.  ft.  pasta— M. 

(J.  Foster  Flagg.) 
Creosote  may  be  substituted  for  oil  of  cloves  or  phenol. 

IJ — ^Acidi  arsenosi gr.  x 

Cocainse  hydroch gr.  xx 

Olei  cinnamomi q.  s.  ft.  pasta — M; 

(E.  C.  Kirk.) 

I^ — ^Arsenic .      .     gr.  x 

Alum .     gr.  X 

Thymol  .      , gr.  x 

Oil  of  cloves q.  s.  ft.  pasta — M. 


440     REMOVAL  OF  DENTAL  PULP  AND    ROOT-CANAL   FILLING 

As  the  ordinary  pastes  tend  to  separate  into  layers  of  arsenic, 
morphin,  etc.,  and  menstruum  if  made  thin,  they  should  either  be 
made  into  stiff  pastes  or  spread  over  the  bottom  of  a  wide  jar,  so  that 
some  arsenic  may  be  scraped  off  the  bottom  at  each  application. 

W.  H.  Truman  indorses  the  opinion  of  J.  D.  White  that 
thorough  trituration  for  two  hours  more  finely  divides  the  arsenic 
and  prevents  separation,  and  claims  that  the  use  of  arsenic 
triturated  with  wood  creosote  and  glycerin  is  the  most  effective 
preparation.^ 

Miller  offers  the  following  general  rules  as  deductions  from  his 
observations : 

"1.  The  rapidity  and  intensity  of  the  action  of  arsenous  acid 
depend,  under  certain  circumstances,  to  a  very  considerable  degree 
upon  the  substance  or  substances  with  which  it  is  incorporated. 

"2.  Where  there  is  but  a  small  point  of  exposure,  and  in  particular 
where  extensive  calcification  has  taken  place  in  the  pulp,  escharotics 
should  be  avoided,  since  the  coagulation  of  the  tissue  retards  the 
absorption  of  the  arsenic.  This  retardation  is  but  slight  where  there 
is  a  broad  surface  of  exposure.  In  stubborn  cases,  where  applica- 
tions of  the  ordinary  paste  fail  to  effect  the  devitalization,  a  paste 
consisting  of  arsenous  acid  in  oil  of  cloves,  glycerin,  or  salt  solution 
should  be  employed,  undiluted  by  any  third  constituent. 

"3.  Thymol  is  worthy  of  a  trial  as  a  substitute  for  morphin,  on 
account  of  its  anesthetic  and  antiseptic  properties. 

"4.  For  devitalizing  pulps  of  temporary  teeth  or  remains  of  pulp 
tissue  in  root  canals,  arsenous  acid,  if  employed  at  all,  should  be 
diluted  with  two  or  three  parts  of  some  other  constituent  (thymol, 
zinc,  oxid,  morphin,  iodoform)." 

Cobalt  was  introduced  by  Robert  Arthur  as  a  devitalizing  agent 
some  forty  years  ago.  Within  recent  years  it  has  been  employed, 
notably  by  the  Herbst  method,  to  destroy  pulps.  The  cobalt  paste 
of  Herbst  was  analyzed  by  E.  C.  Kirk,  and  found  to  consist  of 
metallic  arsenic  and  cocain  hydrochlorid.  Kirk  suggests  that  free 
acids  which  cocain  salts  may  contain,  or  the  chlorin  from  the  chlorid, 
may  combine  with  the  metallic  arsenic  and  form  soluble  salts.  The 
use  of  arsenic  pentoxid  and  soluble  arsenates  has  been  suggested  by 
Fette,  and  for  which  he  claims  advantages.^ 

Fette^  recommends  the  use  of  arsenic  pentoxid  formed  into  a  paste 
with  glycerin  as  applicable  upon  inflamed  pulps  as  even  at  times 
relieving  pain  and  ordinarily  not  causing  any. 


1  Dental  Brief,  June,  1913.  2  Dental  Cosmos,  November,  1914. 

3  Ibid.,  p.  1240. 


DEVITALIZATION  OF  THE  PULP  441 

Briin^  strongly  recommends  chemically  pure  cobalt  and  cocain 
hydrochlorid  equal  parts  plus  carbolic  acid  as  having  satisfactory 
devitalizating  action,  not  passing  the  foramen,  not  causing  gum 
necrosis  and  even  acting  through  dentinal  fibers. 

His  variants  are:  (1)  with  formocresol  for  purulent  pulpitis;  (2) 
with  sodium  hydrate  10  per  cent,  in  children's  teeth;  (3)  to  avoid  pain 
applying  without  excavation  and  repeating  the  next  day  after  excava- 
tion; (4)  with  mucous  anesthetic  injection  applied  to  pulp  stumps 
after  removal  of  the  bulb  only.  In  this  case  on  a  ball  of  cotton, 
wet  with  phenol  and  dipped  into  cobalt  powder.  A  week  or  more  is 
required  for  devitalization.  The  covering  preferred  is  zinc  oxid  and 
eugenol  into  which  cotton  is  incorporated  at  the  time  of  mixing;  on 
account  of  discoloration  the  method  is  confined  to  molars. 

There  are  some  advantages  in  the  so-called  devitalizing  fiber  intro- 
duced by  J.  Foster  Flagg.  To  make  this,  absorbent  cotton  is  cross-cut 
with  scissors  to  a  fine  lint  or  short  fibers.  This  is  dusted  into  the  paste 
or  ground  up  with  it  in  the  mortar.  It  may  then  be  dried  on  a  blotter 
and  be  bottled  for  use.  As  it  lacks  long  fibers,  a  small  portion  may  be 
detached  and  be  placed  upon  the  pulp.  There  are  cases,  however, 
in  which  the  paste  should  be  carried  to  the  exposure  upon  a  probe 
and  gently  inducted  into  a  fine  exposure.  Here  its  tendency  to  spread 
or  penetrate  is  valuable.  The  fiber  has  no  such  tendency,  which 
makes  it  less  dangerous  in  use.  In  making  the  application  a  minute 
portion  of  paste  is  to  be  laid  upon  the  pulp,  or  a  pin-head  pellet  of 
cotton  is  rolled  in  it,  the  excess  of  menstruum  removed,  and  it  is 
then  applied  to  the  pulp,  or  a  portion  of  devitalizing  fiber  is  used. 
This  is  then  sealed  in. 

The  cavity  should  be  prepared  for  the  reception  of  arsenic,  decay 
being  removed  as  far  as  practicable,  and  the  cavity  dried.  Any 
redundant  gum  must  be  pressed  away  or  saturated  with  trichloracetic 
acid  and  ablated  or  removed  with  the  electric  cautery. 

In  some  bad  cases  with  much  gum  overlying  the  \vTiter  has  furnished 
pliers  and  directed  the  use  of  cotton  pellets  to  be  dipped  into  an 
aqueous  antiseptic  (Listerine,  Borine,  etc.),  warmed  in  a  flame  and 
placed  in  the  cavity  by  the  patient.  This  coincidently  sedates  the 
pulp. 

There  are  three  good  methods  of  sealing  the  arsenic.  (1)  In  cases 
not  approaching  the  gum,  or  where  dryness  can  be  maintained,  the 
application  may  be  accurately  made  and  quick-setting  cement  flowed 
over  it.  This  cement  is  capable  of  being  fairly  dropped  into  a  cavity  or 
led  around  the  periphery  by  a  probe,  and  should  be  very  adhesive,  also 

1  Dental  Cosmos,  April,  1917,  p.  433. 


442     REMOVAL  OF  DENTAL  PULP  AND   ROO f -CANAL  FILLING 

be  readily  removable.  (2)  The  arsenic  may  be  applied  preferably  "  fiber' ' 
and  a  metal  or  gutta-percha  cap  (the  latter  purchasable)  placed,  liberally 
covering  it  to  prevent  pressure,  temporary  stopping  or  cement  is  then 
packed.  (3)  A  still  safer  method  consists  in  applying  a  pellet  of 
amadou  over  a  part  of  the  pulpal  wall.  The  cement  is  then  introduced 
about  the  periphery  of  the  cavity,  the  amadou  being  left  largely 
uncovered.  When  hard,  any  cement  over  the  amadou  is  removed 
and  the  latter  lifted  out,  thus  leaving  a  box-like  receptacle  for 
the  arsenic  and  a  pellet  of  cotton  partly  wet  with  eugenol  in  which 
menthol  is  dissolved.  When  placed,  the  orifice  is  dried  and  more 
cement  added.  This  method  of  first  making  the  covering  is  of  special 
advantage  when  the  ca^dty  cervix  is  near  the  gum,  and  prevents  the 
forcing  of  arsenic  toward  the  gum  in  the  act  of  making  the  covering. 

Amalgam  or  facing  amalgam^  or  tempo- 
FiG.  391  rary  stopping  may  be  used  in  place  of  the 

cement  (Fig.  391).  Temporary  stopping 
is  not  very  safe  against  masticatory  force. 
In  a  very  difficult  case  of  a  distocervical 
cavity  with  partial  pulp  death  in  a  lingual 
root  the  occlusal  opening  shown  in  Fig. 
329  was  made  and  an  artificial  canal  con- 
structed as  there  shown;  arsenical  fiber 

Diagram  showing  method  of       waS  then  applied  to  the  pulp. 
first  making  the   covering  for  t  .lI  •  i  •   i  i  i  i 

an  arsenical  or  sedative  appii-  ^^^  another  case,  ui  which  Only  a  buccal 
cation,    csee  text.)    EP,  ex-     wall  was  Standing,  the  pulp  within  the  Open 

posed  pulp;  AA,  arsenical  ap-  -,  i    ,•  i-     i  i  i 

plication;  c,  sedative  covering  ^aiial,  a  sedative  was  applied  and  covered 
to  same;    A,  amalgam  placed     with  saudarac  vamisli  on  cottou  to  prcss 

before  these  applications;    A',  ,    ,  i  n,  j-        n  ^ 

amalgam  to  seal  them  in;  E,  o^^^  ^hc  gum;  after  cxcavatiou the  pulpwas 
enamel.  covercd  with  a  pellet  of  devitalizing  fiber 

and  this  with  a  pellet  of  spunk ;  over  this 
a  permanent  amalgam  and  cement  combination  filling  was  built. 
This  was  later  perforated  to  the  spunk  before  thorough  hardening. 
This  opening  was  then  filled  with  soft,  quick-setting  cement.  This 
was  for  subsequent  treatment  without  annoyance.  Such  a  method 
has  a  wide  variety  of  applications. 

The  rubber  dam  is  generally  insisted  upon,  but  cannot  be  used  in 
the  worst  cases,  hence  an  expert  may  dispense  with  it.  There  is  a 
tendency  among  students  to  rely  upon  the  rubber  dam  alone  to 
prevent  accidents.  This  is  a  fallacy,  as  the  same  results  may  occur 
with  it  as  well  as  without  it.  The  chief  danger  lies  in  the  use  of 
temporary  stopping  after  placing  paste.  .  Capillarity  and  pressure 

1  Facing  amalgam  is  silver  40,  tin  55,  zinc  5  parts,  and  mercury. 


DEVITALIZATION  OF  THE  PULP  443 

often  carry  the  paste  to  the  cervical  margin.    jNIaking  the  covering 
first  or  using  fiber  constitute  the  best  precautions. 

In  case  of  a  very  dangerous  cavity,  as  a  distocervical  one,  a  special 
drill  pit  known  as  a  "pocket"  is  to  be  made  at  some  other  point 
extending  in  the  direction  of  the  pulp  horn  and  as  near  to  it  as  can 
be  made  without  too  much  infliction  of  pain.  In  this  the  arsenic  is 
to  be  sealed  while  antiseptic  sedatives  are  to  be  placed  on  cotton  in 
the  cavity  of  decay,  the  first  application  devitalizes  the  fibrils  and 
permits  deeper  ones.  This  method  is  also  valuable  when  the  pulp  is 
very  irritable,  and  permits  devitalization  through  a  more  or  less 
healthy  portion  of  pulp. 

The  presence  of  pulp  nodules  may  necessitate  an  application  after 
lifting  away  the  nodule  (Fig.  346). 

The  arsenical  method  may  be  used  after  a  preliminary  general 
anesthesia  and  bulb  removal,  or  may  even  be  used  against  an  obdurate 
pulp  canal  filament. 

Symptoms. — The  large  majority  of  pulps  die  under  arsenic  with 
but  little  pain.  Sometimes  throbbing  pain  results,  passing  into  a 
heavy  fulness  as  congestion  supervenes.  If  too  great,  the  pulp  should 
be  uncovered  and  bled  slightly,  then  a  sedative  should  be  applied, 
iodin  used  as  a  counterirritant  upon  the  gum,  and  pulp  death  awaited. 
Ordinarily  the  pain  passes  away  as  the  pulp  becomes  more  fully 
congested.  Apical  irritation  ma}'  result  and  may  be  ignored  if  slight, 
or  if  severe  be  treated  in  the  same  way  as  the  pulp  irritation  (Fig. 
354).  A  guard  to  prevent  overocclusion  is  sometimes  useful  but 
seldom  required  (Fig.  504). 

Accidents  from  Arsenical  Applications. — If  a  portion  of  an  arsenical 
application  escape  from  beneath  its  covering,  it  may  destroy  much 
or  a  little  gum  tissue,  according  to  the  amount  which  escapes.  The 
teeth  should  be  seen  early  in  doubtful  cases  and  the  condition  of 
the  gum  observed. 

The  arsenic  may  attack  the  gum  festoon,  inducing  in  it  stasis 
followed  by  necrosis.  The  gum  assumes  a  purplish  turgidity,  which 
later  changes  to  a  dirty  yellow  slough. 

The  bone  is  usually  devitalized  for  a  distance. 

If  the  necrosis  be  self-limited,  as  is  usually  the  case,  a  small 
sequestrum  comes  away  after  a  few  weeks.  To  prevent  necrosis  of 
the  gum,  it  has  been  suggested  that  phenol  be  applied  as  arsenic  does 
not  pass  through  dead  tissue  but  the  slough  produced  by  phenol  if 
effectively  applied  causes  doubt  as  to  whether  it  might  be  due  to  arse- 
nic.    Care  in  application  is  better,  any  slough  to  be  treated  at  once. 

In  some  cases  the  arsenic  may  follow  the  festoon  of  the  gum  of 
one  or  more  teeth,   causing  disagreeable  sloughs  and  ulcerations. 


444      REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL  FILLING 

It  may  follow  the  pericemental  tract,  kill  the  pericementum,  and  the 
tooth  drops  out.  In  one  case  of  a  boy,  aged  twelve  years,  an  appli- 
cation was  made  in  a  first  lower  molar.  A  blow  from  a  base-ball 
was  subsequently  received  and  a  slight  leakage  occurred  merely  a 
trifling  slough  of  the  gum  being  apparent  mesially.  Later  the 
living  gum  margin  appeared  flabby  and  could  be  lifted  away.  Finally 
and  gradually,  during  nine  months,  the  buccal  pocket  deepened 
without  loss  of  the  gum,  the  tooth  gradually  loosened,  the  bone 
septum  between  the  roots  was  found  necrosed,  the  tooth  was  removed, 
and  the  socket  healed  without  further  necrosis.  The  alveolar  process 
about  one  or  several  teeth  may  be  devitalized  and  a  sequestrum 
occur  which  includes  the  teeth.  Certain  toothache  nostrums  are 
sold  which  contain  arsenic.  Dr.  G.  C.  Chance^  recorded  a  case  of 
arsenical  necrosis  occurring  from  this  source.  Dr.  J.  E.  Powers^ 
recorded  a  case  in  which  extensive  necrosis  occurred  from  the  use 
of  colored  woolen  yarn  (as  a  cleanser  of  interdental  spaces)  which 
contained  arsenic  used  in  the  dye. 

Fig.  392 


Boenning's  case  of  coagulation  necrosis  due  to  arsenic;  shows  exposed  and  blackened 

alveolar  process. 


From  the  infirmary  of  the  Philadelphia  Dental  College  was  re- 
ferred to  the  oral  clinic  a  case  of  extensive  coagulation  necrosis, 
resulting  from  the  rubbing  of  "toothache  drops"  upon  the  gum. 
Analysis  showed  the  preparation  used  contained  arsenic.  Collapse 
from  blood  poisoning  being  the  immediate  danger,  the  child  was 
operated  upon  by  Prof.  Boenning  for  drainage  of  the  parts.  During 
the  recovery,  the  teeth  from  the  right  lower  cuspid  to  the  left  lower 

1  Proceedings  of  the  Academy  of  Stomatology,  Philadelphia,  1898. 

2  International  Dental  Journal,  November,  1902. 


DEVITALIZATION  OF  THE  PULP  445 

second  temporary  molar,  and  the  gums  over  the  process,  were  lost, 
leaving  a  blackened  alveolar  process,  to  be  later  removed  surgically 
(Fig.  392).^ 

Arsenic  is  liable  to  pass  through  the  apical  foramina  of  unformed 
or  much  resorbed  roots.  It  may  possibly  pass  through  mature  roots 
when  an  application  is  placed  high  up  in  the  canal,  rarely  when  applied 
under  normal  conditions  (as  recorded  by  some),  or,  as  occurred  in 
one  case,  by  the  application  being  pushed  through  the  apex.  It 
may  be  forced  through  in  the  act  of  broaching,  or  through  the  sub- 
sequent use  of  the  cataphoric  current  or  pressure  anesthesia  without 
the  preliminary  precaution  of  removing  the  arsenic. 

In  some  cases  arsenic  has  been  applied  to  perforations  made 
through  the  sides  of  roots  under  the  impression  that  the  vital  tissue 
found  was  pulp  tissue.  In  such  case  its  necrotic  effects  will  be  noted 
upon  the  gum  overlying  the  root  apex  or  over  the  perforation,  the 
tooth  being  loosened  and  extruded  and  may  possibly  be  lost. 

E.  C.  Kirk^  has  recorded  several  cases  of  loss  of  teeth  from  arsenical 
necrosis  of  the  pericemental  tissue  follo\\ang  the  use  of  mummifying 
paste  to  pulp  stumps  previously  impregnated  with  arsenic.  His 
theory  is  that  the  arsenic  was  liberated  by  the  affinity  of  the  ingre- 
dients of  the  mummifying  paste  for  the  proteid  constituents  of  the 
pulp  tissue.  The  editor  has  often  used  such  pastes  after  arsenic  and 
without  untoward  results,  and  feels  that  some  other  element  must 
have  entered  in  Kirk's  cases. 

Such  dangers  as  these  demand  that  extreme  precautions  be  taken 
against  the  careless  use  of  quantities  of  the  agent.  The  rules  laid 
down  should  be  adhered  to. 

The  only  cure  of  the  condition  consists  in  the  thorough  removal  of 
every  particle  of  the  arsenic.  Any  projecting  masses  of  edematous 
sloughing  or  gum  should  be  cut  away,  as  they  are  dead  and  will  slough 
at  any  rate,  and  a  freer  access  to  deep  parts  is  had — the  blood-flow 
may  itself  wash  away  the  arsenic.  The  forcible  washing  should  be 
prolonged  and  repeated,  or  10  per  cent,  silver  nitrate  should  be  used 
to  form  arsenite.  Tincture  of  iodin  may  be  applied,  with  a  view  to 
possible  neutralization  of  the  arsenic,  and  as  a  disinfectant.  Next, 
euroform  paste  is  applied  on  cotton  and  renewed  as  necessary.  The 
mouth  is  to  be  kept  as  aseptic  as  possible  with  washes. 

I^ — Orthoform 40  parts 

Europhen 60  parts 

Liquid  petrolatum q.  s. — M.  (Buckley.) 

The  editor,  in  a  case  of  known  application  of  arsenic  to  an  obscure 

1  Dental  Cosmos,  October,  1903. 


446     REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL  FILLING 

perforation,  succeeded  in  causing  regeneration  of  tissue  by  removing 
surgically  the  dead  tissue  and  inviting  repair. 

It  may,  therefore,  be  that  after  minute  portions  of  arsenic,  forced 
through  foramina,  exert  their  full  effect,  the  resulting  dead  tissue 
may  be  removed  by  resorption  or  even  exfoliation;  indeed,  this  result 
has  been  noted  in  which  no  other  explanation  seemed  possible. 

If  the  teeth  are  loosened  and  lost  as  the  result  of  arsenical  necrosis, 
either  beginning  at  the  gum  margin  or  at  the  apical  space,  the  alveolus 
will  exhibit  a  bare  periphery  and  even  some  odor  of  putrefaction  may 
be  present.  The  alveolus  should  be  sterilized  and  the  walls  burred 
away  to  a  tissue  capable  of  healthy  granulation. 

Special  Methods  of  Preparing  Pulps  for  Removal, — A  fully  exposed 
pulp  in  a  single-rooted  tooth  or  single  root  of  a  multirooted  tooth, 
may  be  suddenly  "knocked  out"  by  means  of  a  delicately  pointed 
orange-wood  stick  or  Portuguese  toothpick.  The  point  is  dipped 
in  phenol  and  suddenly  and  boldly  driven  into  the  pulp,  either  by 
hand  or  mallet  force.  The  method  is  not  so  agreeably  delicate  as 
pressure  anesthesia,  but  is  effective  and  if  completely  and  accurately 
done,  not  painful.  It  must  not  be  used  in  partial  exposure,  as,  not 
reaching  the  apex,  it  may  cause  pain.  Its  use  is  only  indicated  in 
emergency  or  occasionally  in  crown  work  after  excision  of  the  crown 
by  excising  forceps  from  which  some  shock  anesthesia  may  result. 

A  vital  remnant  of  pulp  may  be  removed  after  instilling  a  strong 
cocain  solution,  or  carbolic  acid,  or  a  paste  of  carbolic  acid  and 
acetate  of  morphin,  into  its  substance  by  means  of  a  "puncture 
probe."  This  instrument  may  be  made  by  filing  down  a  Donaldson 
bristle  to  a  fine  point,  which  is  further  whetted  on  an  oil  stone.  The 
sides  of  the  probe  are  polished  by  folding  a  cuttle-fish  disk  upon 
itself,  holding  it  between  the  thumb  and  forefinger  of  the  left  hand, 
and  drawing  the  probe  through  it.  The  pulp  canal  is  flooded  with 
the  carbolic  acid,  and  gentle  thrusts  are  made  into  the  pulp  until  the 
probe  is  stopped  at  the  apex.  If  it  pass  through,  that  must  be  judged 
by  the  sense  of  touch.  Custer  recommends  75  to  90  per  cent,  sul- 
phuric acid  as  superior  to  carbolic  acid.  At  times  a  small  end  of 
pulp  filament  may  be  seared  with  a  hot  Evans'  root  drier,  which  is 
quickly  thrust  into  it.    This  does  not  necessarily  give  much  pain. 

A  slow  but  effective  method  of  disposing  of  these  filaments,  when 
hyperirritable  or  when  patients  are  timid,  consists  in  packing  a 
cotton  twist  saturated  with  carbolic  acid  containing  cocain  hydro- 
chloride in  solution  into  contact  with  the  pulp,  and  then  gently 
compressing  the  pulp.  The  cotton  is  to  be  left  in  position  for  a  day 
or  two  to  induce  thrombosis,  when,  as  a  rule,  the  pulp  may  be  removed. 
A  dressing  of  tincture  of  iodin  has  been  suggested  for  the  purpose. 


THE  EXTIRPATION  OF  THE  PULP 


447 


Erythrophlein  Hydrochlorid. — ^Norman  Black  (Scot- 
land) introduces^  throphleol  (erythrophlein  hyd.,  50 
per  cent,  solution  in  eugenol).,  applied  on  the  tiniest 
possible  pellet  of  cotton  to  the  center  of  the  pulpal 
wall  of  a  deep  cavity  (away  from  the  pulp  in  old 
exposures  or  smeared  on  the  pulpal  wall  of  shallow 
cavities,  to  be  tightly  sealed  in  with  temporary  stop- 
ping or  cement  for  forty-eight  hours.  He  finds  the 
pulp  as^  a  white,  bloodless,  insensitive  thread  with 
tendency  to  shrinkage ;  slight  pericemental  irritation 
may  occur.  The  application  is  relatively  painless, 
sure  and  speedy  and  valuable  in  cases  of  intolerant 
patients.  Being  a  powerful  drug  internally  its  dosage 
of  JO"  to  yV  grain  should  be  borne  in  mind. 

Devitalization  of  Pulps  in  Temporary  Teeth. — All 
of  the  anesthetic  measures  are  as  applicable  to 
temporary  teeth  as  to  the  permanent  ones  if  the 
little  patient  will  tolerate  their  application. 

If  the  child  present  an  exposed  pulp  in  a  tooth 
the  roots  of  which  are  not  resorbed,  arsenic  much 
diluted,  may  be  applied  for  twenty-four  hours  and 
then  be  removed,  the  pulp  being  then  allowed  to  die. 
When  roots  are  resorbed  B run's  cobalt  method  or 
Black's  throphleol  method  may  be  warrantable  ap- 
plications. Dunbar-  has  advised  one  or  two  appli- 
cations of  aqua  ammonise  on  cotton.  Pulp  capping 
may  occasionally  be  done. 

Darby  has  used  cantharides,  2"V  grain  in  carbolic 
acid,  with  success.  It  must  be  carefully  sealed,  as 
strangury  is  a  possibility.^  Figs.  35,  43  and  50  are 
guides  as  to  the  condition  of  the  end  of  the  root.  In 
case  of  pulp  exposure  when  the  root  is  much  resorbed 
only  local  anesthesia  is  permissible  with  such  root 
filling  as  is  possible  (see  pages  475  and  479) ;  when 
nearly  ready  to  be  shed  the  tooth  is  better  extracted, 
though  capping  may  be  tried  if  necessary. 


Fig.  393 


THE   EXTIRPATION    OF    THE   PULP. 

The  extirpation  of  the  pulp  sometimes  must  be 
immediate  for  relief  of  pulpitis.  This  may  be  done 
without  resort  to  radiography  and    after  the  first 

1  Dental  Cosmos,  April,  1919. 

'  Quoted  by  Goddard,  American  Text  Book  of  Oper.  Dent. 

'  Dr.  J.  Foster  Flagg  had  such  a  case. 


Evans's  root  drier. 


448     REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL   FILLING 

dressing  a  radiograph  taken.  At  this  time  the  canal  may  be 
flooded  with  campho-phenique,  etc.  and  a  copper  or  other  metal 
point  or  strand  of  picture  wire  may  be  passed  to  the  apical  region 
and  sealed  in.  The  radiograph  will  then  be  a  still  better  guide  to 
further  procedure. 

In  cases  in  which  later  pulp  removal  or  any  canal  work  is  intended 
the  radiograph  should  be  taken  before  the  next  sitting.  In  cases  of 
apical  disease,  known  or  suspected,  the  radiograph  being  a  means  of 
diagnosis  should  have  been  previously  taken. 

In  cases  associated  with  pulp  putrefaction  formocresol  or  Howe's 
method  should  have  been  used  for  sterilization  as  far  as  may  be. 
Thus,  what  is  stated  for  a  vital  pulp  as  to  the  mechanical  opening 
of  the  canal  applies  to  all  cases,  except  as  to  indicated  antisepsis  and 
removal  of  canal  fillings  in  septic  cases.  These  are  explained  under 
the  various  headings. 

For  the  insurance  of  asepsis  provision  should  be  made  for  the 
facile  adjustment  of  the  rubber  dam,  in  case  the  cavity  extends 
beneath  the  gum.  This  may  be  accomplished  by  thoroughly  excavat- 
ing the  cavity  and  preparing  the  cervix  for  a  filling.  If  in  posterior 
teeth  and  amalgam  to  be  eventually  used  this  may  be  built  in  per- 
manently after  placing  spunk  or  temporary  stopping  over  or  into  the 
pulp  chamber;  later  this  stopping  is  removed,  a  germicidal  dressing 
placed  and  canal  work  done  later.  An  alternative  consists  of  building 
cement  temporarily  into  this  wall,  another  the  adjustment  of  a  thin 
ready-made  band  of  German  silver  with  cement  or  tem}  Ox-ary  stop- 
ping to  enclose  the  cavity  cervix  and  the  tooth.  In  case  of  roots 
such  a  ferrule  is  adjusted  and  allowed  to  protrude  above  the  gum. 
It  may  remain  or  be  removed  at  each  sitting  if  in  anterior  teeth  a 
temporary  crown  be  necessary.  The  use  of  light  clamps  such  as  the 
Palmer  set  placing  the  clamp  in  position  and  throwing  the  dam  over 
the  clamp,  adjusting  a  ligature  and  the  use  of  the  saliva  ejector  as  an 
adjunct  complete  the  rubber  dam  preparation.     (Fig.  485.) 

The  field  of  operation  should  be  sterilized  with  tincture  of  iodin 
or  phenol  followed  by  70  per  cent,  alcohol.  Rubber  dam  not  contain- 
ing any  starchlike  treatment  to  react  with  iodin  is  to  be  preferred. 
These  precautions  are  supplemented  by  the  use  of  properly  sterilized 
instruments,  hands,  cotton,  paper  points,  etc.,  and  possibly  by 
phenol  in  the  pulp  cavity.  If  napkins  must  be  used,  as  strict  asepsis 
as  possible  must  be  employed.  This  applies  also  to  the  pulp  anesthe- 
sias (see  Chapter  on  Asepsis). 

Free  access  to  all  parts  of  the  pulp  cavity  and  canals  must  be 
obtained.  This  is  usually  best  accomplished  by  an  opening  made  in 
direct  line  with  the  axis  of  the  pulp  canal.    In  general  terms  this 


THE  EXTIRPATION  OF  THE  PULP 


449 


involves  for  sound  teeth  an  opening  upon  the  Hngual  surface  of 
incisors  and  cuspids  and  upon  the  occlusal  surface  of  bicuspids  and 
molars. 

This  access  may  consist  of  a  new  opening  or  an  extension  of  a 
cavity,  or  at  times  the  cavity  and  canal  may  simply  be  made  con- 
tinuous. 

When  a  ca^-ity  of  decay  exists  the  pulpal  wall  should  be  perforated 
and  a  large  bud  bur  should  be  used  to  cut  away  the  dentin  over- 
hanging the  pulp  cavity.  It  is  usually  necessary  to  extend  the  cavity 
in  the  central  occlusal  direction,  so  as  to  permit  direct  access  to 
each  canal  (Figs.  394  to  401). 


Fig.  394 


Fig.  395 


Fig.  396 


Fig.  397 


Fig.  398 


Fig.  399 


Fig.  400 


Fig.  401 


When  a  tooth  crown  would  be  irremediably  weakened  by  such  a 
course,  a  slight  indirectness  is  permissible  when  flexible  cleansers 
can  be  used  instead  of  drills.  This  leaving  of  tooth  structure  should 
be  done  with  judgment.  The  canals  must  be  cleansed.  In  cavity 
approaches  the  older  wall  of  the  pulp  cavity  should  be  cut  away  to 
permit  an  obtuse-angled  approach  rather  than  a  right-angled  one 
(Figs.  399  and  401).  All  pulp  cavity  corners  should  be  burred  to 
a  shape  that  obviates  retention  of  pulp  debris,  the  subsequent  decom- 
position of  which  would  lead  to  discoloration  and  infection.  The 
opening  sho^\Ti  in  Fig.  397,  B  is  faulty  for  this  reason,  and  is  better  if 
39 


450     REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL  FILLING 

extended  more  toward  the  incisal  edge,  making  an  oblong  opening 
with  rounded  ends. 

In  sound  teeth  the  entrance  to  the  canal  is  made  with  a  small 
spear  drill,  after  the  enamel  has  had  a  "spot"  made  in  its  surface 
with  a  sharp  dentate  bur.  This  centers  the  spear  drill  and  prevents 
its  slipping  about.    After  it  has  entered  the  pulp  cavity  dentate  burs 


Fig.  402 


Fig.  403 


12     3     4      5     6 

12      3      4      5       6 

IH  XP    F     M     C    XC 

XXF   XF     F     M     C     XG 

Style    D 

Style  D 

Kerr  root  canal  probes. 

Kerr  root  canal  files. 

are  used  to  enlarge  the  opening  to  the  desired  size  and  shape.  A 
sawing  motion  creates  more  rapid  clearance  and  cutting  of  tooth 
tissue. 

One  should  not  always  suppose  that  the  spear  drill  will  drop  into 
an  appreciable  pulp  cavity.  The  careless  driving  of  a  drill  into  a 
tooth  may  cause  a  perforation.  Secondary  dentin  or  a  large  nodule, 
and,  in  previously  treated  teeth,  zinc  phosphate  may  occupy  the 


THE  EXTIRPATION  OF  THE  PULP 


451 


pulp  chamber.  Therefore,  when  doubt  arises,  open  well  that  portion 
of  tooth  or  filling  which  has  been  drilled  through,  and  note  the 
conditions,  then  go  ahead  carefully.  In  opening  a  located  pulp 
chamber  with  burs  a  bud  bur  is  very  useful,  but  all  burs  once  placed 
through  the  drill  hole  and  into  the  pulp  chamber  must  be  used 


Fig.  404 


Fig.  405 


Fig.  406 


Fig.  407 


Fig.  408 


Donaldson's  pulp-canal  cleansers. 

laterally  or  the  heel  of  the  bur  used  with 
an  outward  sweep  toward  the  occlusal  aspect 
for  the  sake  of  safety. 

Large  Canals. — ^The  canal  (or  canals)  is 
now  to  be  explored  with  a  fine,  sterile,  smooth 
broach  (Fig.  402),  and  if  of  operable  size  a 
Donaldson  cleanser  (Fig.  404)  is  passed  to 
the  canal  apex,  twisted  so  as  to  engage  its 
teeth  with  the  pulp  substance,  and  the  pulp 
extirpated.  An  apexographer  or  fine  barbed 
cleanser  somewhat  of  the  Donaldson  type 
with  a  few  teeth  on  the  apical  end  only  is 
useful  in  removing  a  last  bit  of  pulp  or  defin- 
ing the  apical  foramen. 

If  there  be  any  difficulty  in  finding  the  canals 
after  preparation  of  the  bulb  of  the  pulp  cavity 
hy  reason  of  the   broach  catching  on  the 

edge  of  the  orifice,  the  mouth  of  the  canal  should  be  made  continuous 
with  the  wall  of  the  pulp  chamber  by  means  of  a  small  bud  bur, 
occasionally  with  a  Gates-Glidden  drill.  The  wall  then  leads  the 
broach  into  the  root  lumen.  Care  must  be  taken  not  to  penetrate 
the  side  of  the  root  and  create  a  catch  for  instruments.     The  Rhein 


Donaldson's    spring-tem- 
pered nerve  bristles. 


452     REMOVAL  OF  DENTAL  PULP  AND    ROOT-CANAL  FILLING 

picks  (Fig.  409)  being  strong  probes  with  sharp  points  are  useful 
in  jamming  an  opening  through  constrictions  at  the  canal  orifice. 

Fig.  409 


Rhein  picks.     (Courtesy  J.  W.  Ivorj\) 

Subsequent  enlargements  are  to  be  made  with  Kerr  root  files 
(Fig.  403) ,  inserted  to  full  depth  and  used  as  a  file  with  outward  sweep 
and  lateral  pressure  or  with  Donaldson  cleansers  in  the  same  way. 
Fine  tapering  sizes  are  first  used  then  the  larger  ones. 

Fig.  410 


r 


8 

D 


Kerr  or  Downie  broaches.     Various  finer  sizes  of  these  broaches  and  reamers  may 
be  had.    They  should  have  accurate  taper. 


Fine  Canals. — These  usually  are  fine  round  or  flattened  and  present 
a  difiiculty  of  exploration.    To  determine  direction  and  penetrability 


THE  EXTIRPATION  OF  THE  PULP  453 

the  finest  Kerr  smooth  broach,  a  Young's  broach  or  a  Kerr  root  file  filed 
to  a  fine  point  is  pressed  gently  toward  the  apex  or  moved  to  and  fro. 
If  the  radiograph  shows  a  root  curved  the  end  is  bent  with  sterile 
pliers  to  conform.  Sulphuric  acid  30  per  cent.,  sodium  potassium 
alloy  picked  by  the  broach  from  its  tube,  or  sodium  dioxid  taken  up 
by  the  wet  broach  usually  aids  in  penetration.  Much  patience  may 
be  necessary  in  reaching  the  apex.  A  bit  of  rubber  dam  as  a  marker 
may  be  put  on  the  shank,  slipped  to  a  guide  point,  preferably  the 
cutting  edge  or  occlusal  surface. 

'This  depth  of  penetration  may  be  gauged  by  the  tooth  length,  as 
shown  in  the  radiograph.  In  this  penetration  the  side  walls  of  the 
canal  support  the  broach  against  buckling.  Larger  sizes  of  smooth 
broaches  should  follow;  next  the  finest  Kerr  root  canal  files;  next 
the  larger  root  canal  files  or  Donaldson  cleanser  when  the  canal 
admits  them. 

In  canal  roots  only  flexible  sizes  of  files  and  occasionally  of  Kerr 
twisted  broaches  can  be  used  without  danger  of  false  pockets  being 
formed  in  the  sides  of  the  canals. 

When  canals  are  determined  and  reasonably  straight,  flexible 
canal  engine  broaches  may  be  used  and  where  dowels  are  intended 
root  reamers  may  be  used  preferably  after  filling  of  the  apex.  When 
it  is  thought  the  apex  is  reached  or  passed,  a  sterile  diagnostic  wire 
is  passed  and  a  radiograph  made  to  determine  the  fact.     (Fig  412.) 

When  an  impasse  is  reached  a  diagnostic  wire  should  be  placed  to 
the  point  usually  after  placing  a  mild  antiseptic  and  sealed  in.  A 
fresh  radiograph  is  taken  and  at  the  next  sitting  (or  the  same  if  neces- 
sary) the  work  is  conducted  in  accordance  with  the  findings  in  further 
endeavor  to  reach  the  apex  either  by  the  same  method  repeated  after 
due  lateral  enlargement  of  the  orifice  of  entrance  if  required  for  better 
direction  or  if  necessary  by  drilling  through  the  apex  m  case  a  granu- 
loma or  abscess  must  be  reached.  The  object  is  to  remove  all  organic 
material  from  the  apical  portion  of  the  canal  and  permit  the  final 
filling  in  as  perfect  a  manner  as  possible.  A  third  radiograph  may 
even  be  necessary  to  determine  the  accomplishment  or  the  nature 
of  the  opening  made.     (Fig.  421.) 

The  failure  to  reach  the  apical  tissue  by  following  the  true  canals 
or  the  making  of  a  perforation  through  the  side  of  a  curved  root  and 
the  breaking  of  the  broaches  are  the  dangers  to  be  encountered. 

This  operation  requires  great  care  and  considerable  skill  and 
involves  much  time  in  some  teeth.  Therefore  before  undertaking  the 
task  the  patient  should  be  acquainted  with  the  circumstances  and  the 
work  undertaken  with  full  recognition  of  the  possibility  of  encounter- 
ing these  drawbacks  and  a  willingness  to  accept  the  outcome.     If 


454     REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL  FILLING 


compensation  is  a  question,  this  should  be  arranged.  Should  the 
attempt  to  reach  the  apical  tissues  fail  after  due  skill  has  been  em- 
ployed we  have  an  apical  end  probably  containing  delta-like  openings 
rather  than  a  single  main  apical  foramen,  or  the  fineness  or  curve 
of  the  canal  has  rendered  opening  impossible.     (Fig.  411.) 


Fig.  411 


Fig.  412 


Delta-like  canals.     (Callahan.) 


Diagnostic  wire  passing  into  apical  tissue. 


Certain  roots  may  be  curved,  yet  have  large  canals  permitting  the 
broach  to  slide  around  the  cur\"e,  while  some  pretty  straight  roots  have 
very  fine  operable  or  inoperable  ones.  Sometimes  the  foramen  may 
be  fair,  yet  to  one  side.  Thus  in  a  splendid  straight  root  held  in  the 
hand,  I  could  approach  the  apex  readily  and  pump  the  canal  contents 


Fig.  413 


Fig.  414 


Fig.  415 


Fig.  416 


through  the  foramen,  but  could  in  no  way  pass  through  it  even  by 
bending  the  broach.  Placing  wires  and  radiographing  may  help,  but 
unfortunately  the  radiograph  is  not  always  a  true  guide. 

Assuming  that  one  has  done  all  work  with  conscience,  the  question 
arises  as  to  the  disposition  of  inoperable  root  ends.    With  a  possible 


THE  EXTIRPATION  OF  THE  PULP  455 

granuloma,  apicoectomy  {q.  v.)  or  extraction  is  the  indication  unless  a 
perforation  can  be  made  and  the  case  cleared  up.  This  latter  only 
when  no  marked  systemic  condition  is  present,  time  for  trial  being 
permissible.  In  fresh  extirpations,  it  seems  that  one  may  try  pumping 
Callahan's  resin  (see  page  469)  into  the  delta-like  foramina  or  the  use 
of  a  paste  and  cone  after  Howe's  treatment  with  ammoniacal  silver 
nitrate.     (See  page  477.)     This  is  on  trial. 

In  canals  of  posterior  teeth  short  instruments  are  momited  in  a 
chuck  handle  and  the  shank  sharply  bent  at  a  right  or  obtuse  angle 
or  soft  soldered  into  a  small  ball  of  metal  and  used  straight  or  used  in 
the  longer  handle  or  the  Kerr  thumb  knob  may  be  grasped  in  a  Jack 
porte.  If  used  short  the  fingers  used  should  be  dipped  in  1  per  cent, 
iodin  trichlorid.  If  the  cleanser  bind  in  the  canal,  it  should  be  grasped 
with  the  thumb  and  forefinger  and  given  a  straight  pull  to  relieve  it. 

If  acid  be  used  it  should  be  neutralized 
with  sodium  bicarbonate  or  sodium  dioxid.  Fig.  417 

The  improved  Gates-Glidden  drill  (Fig. 
417)  has  some  use  in  the  enlargement  of 
canals  the  lumen  of  which  has  been  de- 
termined by  the  above  methods.  They 
should  not  be  used  for  the  preliminary 
opening  of  fine  canals  except  at  the  orifice, 
as  they  tend  to  form  false  channels  in  the         Improved    Gates-Giidden 

.  ,        „    ,  11-1  1  1         nerve-canal    drill    for    engine 

side  01  the  canals  which  constantly  catch     work. 

even  fine  bristles  and  may  render  a  canal 

into  a  form  even  less  advantageous  than  that  it  already  possesses. 

The  canal  filament  of  pulps  in  molars  and  upper  first  bicuspids  may 

be  lifted  away  with  barbed  broaches  or  cleansers  if  the  canals  are 

large,  but  it  is  ordinarily  a  waste  of  time  to  attempt  it  in  the  finer 

canals,  as  the  other  work  must  be  done  in  the  apical  regions. 

The  use  of  5  per  cent,  formalin,  tannin,  or  alum,  to  be  specially 
applied  about  two  days  after  the  application  of  arsenic,  has  been 
suggested  for  the  toughening  of  pulps.  Their  use  necessitates  a  visit 
for  their  special  application.  They  toughen  the  pulp,  and,  while 
the  advantage  in  pulp  removal  is  offset  by  the  special  visit  needed, 
may,  in  fine  canals,  mummify  inaccessible  portions  of  pulp  tissue. 

The  scraping  of  the  canals  removes  the  possible  remnants  of 
pulp  tissue,  odontoblasts,  etc.,  adhering  to  the  dentin  walls,  and 
also  a  part  of  the  wall  with  the  large  ends  of  the  fibrils.  All  these 
are  decomposable  media,  may  become  septic,  and  are  wisely  removed. 

The  final  removal  of  all  pulp  debris,  coagulated  blood,  etc.,  is  best 
done  with  a  fine  Donaldson  cleanser,  moved  to  and  fro  in  the  canal 
with  one  hand,  while  with  the  other  a  stream  of  warm  sterile  water  is 


456     REMOVAL  OF  DENTAL  PULP  AND    ROOT-CANAL  FILLING 

gently  introduced  by  means  of  a  Moffat  syringe.  A  large  cottonoid 
roll  or  a  napkin  may  be  held  by  the  patient  or  assistant  to  absorb 
the  excess  of  moistm-e  when  the  rubber  dam  is  in  position.  When 
cotton  twists  are  to  be  used  they  should  be  would  with  fingers 
dipped  in  H2O2  plus  mercuric  chlorid  (1  to  500)  as  suggested  by 
Ottolengui.  He  states  that  such  a  treatment  is  safe.  One  per  cent, 
iodin  trichlorid  may  also  serve. 


DESCRIPTION  OF  FIGS.  418,  419  AND  420.' 

Fig.  418. — Fig.  3  gives  in  contrast  a  sectional  view  of  deciduous  and  permanent  upper 
teeth  divided  through  their  lateral  diameters. 

Fig.  4,  a  sectional  view  of  the  corresponding  lower  teeth  divided  through  their 
anteroposterior  diameters:  a,  b,  c  represent  respectively  the  deciduous  and  permanent 
front  incisors  in  contrast;  d,  e,  f,  the  lateral  incisors;  g,  h,  i,  the  canines;  k,  deciduous 
molars,  upper  and  lower;  I,  m,  the  successors  to  the  deciduous  molars,  the  bicuspids; 
n,  0,  represent  permanent  molars;  c,  /,  i,  m,  o,  have  dotted  lines  indicating  the  thickness 
of  enamel  removed  by  wear,  atrophy  of  the  cementum,  and  reduction  in  the  size  of  the 
pulp  due  to  progressive  calcification,  these  changes  being  incident  to  old  age. 

Fig.  419  erpresents  in  Fig.  1,  letters  a  to  A  and  a  to  h,  the  longitudinal  or  vertical 
sections  of  the  sixteen  upper  teeth,  showing  the  labiopalatal  diameter  of  the  pulp 
chamber  and  canal  in  crown  and  roots,  the  section  of  the  molars  being  through  the 
anterior  buccal  and  palatal  roots,  while  the  bicuspids  d  e  and  de  illustrate  the  result 
of  such  a  compression  of  the  root  as  to  divide  the  pulp  chamber  into  two  canals — a 
condition  which  so  frequently  exists  in  these  flattened  roots.  The  double-lettered 
series,  d  d  to  h  h  and  dd  to  hji,  represent  in  the  molars  a  section  through  the  posterior 
buccal  and  the  palatal  roots,  from  which  is  quite  readily  recognized  the  slightly  greater 
lateral  diameter  of  the  pulp  chamber  in  the  crown  and  the  larger  canal  in  the  posterior 
buccal  root  over  that  in  the  anterior  buccal  root,  while  the  bicuspids  lettered  e  e  d  d 
and  dd  e  e  illustrate  modified  pulp  chamber  and  canal,  with  bifurcation  of  the  root 
in  one,  these  being  cut  through  a  different  axis  or  plane  from  the  single-lettered  series. 

Fig.  2,  letters  a  to  h  and  a  to  ^,  represent  the  sixteen  lower  teeth  with  the  section 
through  their  long  diameters,  as  in  the  upper  series.  These  incisors  illustrate  the 
compressed  or  flattened  condition  of  their  roots  in  contrast  with  the  cylindrical  char- 
acter of  the  roots  of  the  upper  incisors,  while  the  bicuspids  d  e  and  d_e  illustrate  the 
singleness  of  their  pulp  chamber  and  the  cylindrical  condition  of  their  roots  as  in 
contrast  with  the  flattened  or  compressed  condition  of  the  roots  of  the  upper  bicuspids. 
The  molars  /,  g,  h,  and  /■  g,  h  represent  sections  through  the  anterior  root,  illustrating 
its  compressed  condition  and  divided  pulp  chamber  in  the  first  and  second  molar, 
and  a  somewhat  flattened  one  in  the  anterior  root  of  the  third  molar;  f  f,  g  g,  hh  and 
f  f,  g  g,hh  represent  the  single  and  cylindrical  pulp  chamber  in  the  posterior  root  of 
the  lower  molars,  while  b  b,  c  c  and  a  a,  bb  represent  the  incisors  and  canines  of  the 
same  series,  with  modified  pulp  chambers  arising  from  modified  development. 

Fig.  420. — Fig.  1,  from  a  to  h  and  a  to  A,  represent  the  upper  teeth,  with  transverse 
or  horizontal  section  through  the  base  of  the  pulp  chamber  in  the  crown,  viewing 
the  entrance  to  the  canals  of  the  several  roots,  while  the  same  letters  in  Fig.  2  represent 
the  lower  series  in  the  same  manner. 

Fig.  3  represents  the  upper  teeth,  with  the  transverse  or  horizontal  section  made 
below  the  largest  diameter  of  the  pulp  chamber  and  through  the  canals  after  they 
have  diverged  from  the  central  chamber,  but  before  the  roots  into  which  they  run  have 
in  the  molars  bifurcated. 

Fig.  4  in  like  manner  represents  the  lower  series,  well  illustrating  the  flattened  or 
compressed  condition  of  the  canal  anterior  roots  of  the  molars  and  the  division  of  the 
chamber,  as  is  frequently  found  in  the  roots  of  the  lower  incisors. 

The  letters  aa,bb,cc,dd,  ff,  d_d,  and  e_e  (Fig.  3)  represent  the  relative  shapes, 
whether  circular,  oval,  or  flattened,  of  the  pulp  canal  in  the  roots  of  the  upper  central 
and  lateral  incisors,  the  canines,  the  first  and  second  bicuspids,  and  the  first,  second, 
and  third  molars,  while  the  same  letters  in  Fig.  4  represent  the  relative  shapes  of  the 
pulp  canal  in  similar  teeth  in  the  lower  series. 

1  These  figures  are  taken  from  v.  Carabelli's  Anatomie  des  Mundes. 


457 


458 


ii 


-^4 


SI  CO 

,  fcJD 


^J 


<«>^ 


// 


y* 


to 


.^ 


efc 


bo-'' 


&0 


«^/l 


^^^ 


460     REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL   FILLING 

Tempered  Swiss  broaches  or  prepared  bristles  are  'best  for  handling 
cottons  though  the  Kerr  broach  will  serve  occasionally. 

Fig.  422        Fig.  423     Fig.  424 


Distal 


mesial 


Diag: 
cess  C, 
ting  in 
dotted 
mittin" 


;ram  illustrating  the  improvement  in  ac- 
to  the  deeper  portions  of  enamel  by  cut- 
accordance  with  a  radiograph.  The 
line  shows  the  ordinary  opening  per- 
:  the  access  ii  6.    (Rhein.) 


Upper    lateral    incisors.    (Otto- 
lengui). 


Fig.  425 


Fig.  426 


Fig.  427 


Fig.  428 


Upper  canines. 
Fig.  429 


Fig    430 


Upper  first  bicuspids. 


When  the  broach  must  be  bent  to  enter  canals,  loosen  the  broach 
first  before  introducing  into  the  canal,  thus  leaving  the  cotton 
loosely  mounted  on  the  broach.  To  prepare  a  Donaldson  bristle  cut 
off  the  hook  and  flatten  the  end  upon  an  Arkansas  stone,  and  slightly 


THE  EXTIRPATION  OF  THE  PULP 


461 


flatten  on  two  sides,  then  lay  upon  a  glass  slab  and  burnish  thor- 
oughly to  remove  any  bur  left.  In  use  the  cotton  and  broach  are 
rolled  with  the  left  forefinger  and  thumb  only.  It  is  obvious  that 
to  do  this  the  broach  must  be  perfectly  straight.  When  slightly 
bent  the  method  of  rolling  the  cotton  next  described  may  be  em- 
ployed. The  writer  believes  the  prepared  Swiss  broach  not  only 
more  facile  but  economical  in  use. 


Fig.  431 


Fig.  432 


Upper  second  bicuspid. 
Fig.  433  Fig.  434 


Upper  molar. 


Upper  second  molars. 


To  prepare  broaches,  select  accurately  tapering  Swiss  or  English 
broaches  from  which  the  temper  has  not  been  drawn.  Next,  draw 
the  temper  by  placing  a  few  in  a  test-tube  and  heating  first  at  the 
shank,  gradually  drawing  thp  tube  over  the  flame  toward  the  points. 
The  blue  color  seen  on  the  shank  should  be  run  out  to  the  tip;  let 
cool  on  any  open  surface.  The  soft  broaches  usually  sold  are  nearly 
useless.  The  point  is  left  if  canal  exploration  is  intended.  For 
carrying  cotton  twists,  cut  the  end  off  with  scissors.  To  wind  the 
cotton  lay  a  wisp  on  the  left  forefinger,  lay  the  broach  upon  it,  close 
down  the  thumb,  then  quickly  revolve  the  broach  with  the  right 
forefinger  and  thumb,  pushing  the  cotton  through  those  of  the  left 
hand  to  form  a  symmetrical  cone.  To  use  as  a  swab,  rotate  in  the 
canal  to  the  right.  To  leave  the  cotton  in  the  canal,  rotate  to  the 
right  as  the  twist  is  pressed  to  the  apex.    Then  turn  the  broach  once 


462      REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL  FILLING 

or  twice  to  the  left  to  loosen  it  from  the  cotton,  withdraw  a  little, 
then^  press  in  again.    Thus  the  cotton  is  crimped  upon  itself. 

The  forms  of  normal  pulp  cavities  and  varieties  of  abnormal  root 
are  shown  in  Figs.  418  to  451. 

In  fresh  pulp  removals  a  sedative,  such  as  campho-phenique  plus 
menthol  should  be  sealed  in  until  healing  is  assured  when  the  root  is 
to  be  filled. 

In  cases  originally  septic  the  treatment  is  continued  as  indicated 
under  pulp  putrefaction,  apical  abscess,  etc.     (See  page  493.) 


Fig.  436 


Fig.  437 


Fig.  438 


Fig.  439 


Fig.  440 


Fig.  441 


Upper  molara.  (Ottolengui.) 
Fig.  442  Fig.  443 


Upper  third  molars. 


The  carrying  out  of  canal  treatment  involves  a  knowledge  of  the 
topographical  anatomy  of  the  teeth  and  their  pulp  canals.  As  an 
aid  to  this  Figs.  418,  419,  and  420  are  introduced,  showing  the  normal 
outlines  of  the  teeth  and  their  pulp  chambers. 

In  a  few  cases  in  which  cervical  cavities  obliterate  the  canal  or 
cause  annoying  approach  to  it,  it  is  desirable  to  remedy  the  con- 


THE  EXTIRPATION  OF  THE  PULP 


463 


dition.     In  such  case  the  canals  are  opened  as  usual  and  enlarged, 
and  the  cavity  prepared  with  suitable  retentions  for  filling.     The 


Fig.  444 


Fig.  448 


/" 


^i^>^" 


Fig.  445 


Fig.  446 


Lower  bicuspids. 
Fig.  447 


Lower  first  molars. 


Fig.  449 


Lower  first  molar. 

Fig.  450 


Lower  first  molar,  immature. 
Fig.  451 


Lower  second  molar. 


Lower  third  molar. 


last-used  reamer  is  then  to  be  placed  in  the  canal  and  the  filling 
inserted.    The  filling  is  then  supported  by  pressure  while  the  reamer 


464     REMOVAL  OF  DENTAL  PULP  AND    ROOT-CANAL  FILLING 

is  slowly  twisted  to  the  right  and  withdrawn,  leaving  a  canal  through 
the  filling.    This  may  be  done  with  amalgam  or  with  zinc  phosphate 

if  a  later  removal  be  required.  If  the 
root  be  much  weakened,  a  tapering  dowel 
may  be  cemented  through  the  crown 
and  canal,  thus  attaching  the  root  to  the 
crown  more  firmly  (Fig.  452,  also  page  354) . 
If  intended  the  dowel  is  used  as  the  canal 
former  instead  of  the  reamer. 


Fig.  452 


ACCIDENTS   IN   CANAL    OPENING. 

The  chief  accidents  that  may  occur  are 
the  perforation  of  the  root  wall  and  the 
breaking  of  the  instruments  used.    If  the 

Method    of    restoring  lost       xi,"  i*jj  i,  j?iipii  j 

canal  continuity.    The  cavity     technique  laid  down  be  carefully  followed 
should  have  more  retention     the   danger  of    perforation   is   practically 

form  than  shown ;  a,  amalgam.         r-j.j        T£j.j-T,  xxj 

elimmated.  in  tact,  the  greatest  danger 
is  the  penetration  and  enlargement  of  the 
apical  foramen,  occasionally  of  lateral  perforation  near  the  apex 
(Fig.  468).  Accidents  are  usually  the  result  of  thoughtless  forward 
pressure  of  reamers  and  drills,  and  care  will  reduce  this  to  a  minimum. 
Sometimes  one  must  take  the  chances  with  the  Kerr  engine  or  hand 
reamer,  especially  when  the  shapes  of  roots  are  known  and  an  abscess 
must  be  reached.  When  doubt  exists  as  to  canal  locations,  the  desic- 
cation of  the  pulp  chamber  is  of  great  assistance  by  bringing  them 
into  view,  and  if  secondary  deposits  exist  one  should  always  use  a 
small  bud  bur  and  keep  well  within  the  limits  of  the  dentin  of  a  root 
while  gently  seeking  a  canal  lumen. 

Frequent  exploration  should  follow  gentle  advances,  and,  as  a 
rule,  the  canal  will  be  found  of  fairly  normal  size  just  beyond  the 
point  of  constriction.  In  some  cases  50  per  cent,  sulphuric  acid 
should  be  sealed  against  the  suspected  canal  and  the  operation 
deferred  to  another  sitting. 

If  a  perforation  be  accidentally  made  in  the  lower  part  of  the  canal 
it  may  be  treated  as  shown  on  page  350  and  kept  under  observation. 

One  should  use  every  means  to  diagnose  such  an  opening  if  not 
plainly  such  and  arsenic  should  never  be  applied  to  one.  Cases  of 
extensive  necrosis  have  occurred  from  carelessness  in  this  direction. 
It  may  be  that  the  low  perforations  should  not  be  filled,  but  if  canal 
filling  is  admissible  at  all  the  opening  should  be  sufficiently  large  and 
cone-shaped  throughout  to  admit  a  fair  sized  truncated  cone  handled 
as  for  cases  of  large  foramina  (p.  472)  and  the  end  finally  smoothly 


ACCIDENTS  IN  CANAL  OPENING 


465 


Fig.  453 


bevelled.  Lead  cones  may  also  be  used.  Radiography  will  deter- 
mine if  properly  arranged.  High  perforations  leave  little  to  be  done 
except  apicoectomy  or  reimplantation  if  consented  to  or  desirable. 
The  breakage  of  broaches  is  largely  avoidable  through  the  use  of  new 
instruments  and  by  adhering  to  the  rule  of  using  the  smaller  sizes 
of  mibarbed  broaches  until  the  canals  are  suffi- 
ciently enlarged  to  permit  the  use  of  larger 
sizes,  and,  in  case  of  engine  reamers,  of  start- 
ing the  power  with  the  reamer  loose  in  the 
canal.  The  "pull"  of  an  engine  reamer  must 
be  borne  in  mind  to  avoid  undue  apical  en- 
largement. The  engine  broach  seems  to  be 
of  better  temper  than  the  engine  reamer. 

Accidents  of  this  sort  usually  occur  with 
barbed  instruments  of  the  Donaldson  cleanser 
type,  especially  when  used  with  force. 
Sulphuric  acid  tends  to  disintegrate  the 
broach,  so  that  lactic  acid  is  often  better 
used  with  it,  or  the  alloy  of  sodium  and 
potassium  with  a  smooth  broach  will  open 
the  canal  so  that  the  cleanser  will  not  bind. 
If  it  does  it  should  be  grasped  with  the 
thumb  and  finger  and  given  a  straight  pull. 

While  avoidance  is  far  better  than  the  ap- 
plication of  the  remedy,  if  the  accident  occur, 
the  broach  should  be  removed  if  possible. 

If  lying  loosely  in  the  canal  a  new  root  file 
may  be  passed  to  one  side  of  it  and  then  a 
barbed  cleanser  pressed  against  it.  It  should 
engage  the  barbs  and  jig  it  out. 

Cotton  -vvTapped  on  a  small  Swiss  broach 
may  be  pressed  down  at  one  side  of  the 
broken  broach  and  its  fibers  made  to  engage 
its  barbs. 

Moving  the  broach  back  and  forth  while 
sulphuric  acid,  sodium  dioxid,  or  sodium  and 
potassium  is  about  it,  will  sometimes  loosen 
it.    One  may  sometimes  drill  to  one  side  of  a 

broken  instrument  with  a  Kerr  hand  broach  in  order  to  more  readily 
engage  it  with  a  barbed  instrument.  If  very  loose  a  magnetized 
probe  will  attract  it  and  draw  it  out. 

If  the  broach  be  tightly  fixed  in  the  canal,  sodium  chlorid,  tinc- 
ture of  iodin,  sulphuric  acid,  aqua  regia,  or  25  per  cent,  pyrozone 
30 


Split  and  threaded  in- 
strument for  engaging 
the  shank  of  a  Gates- 
Glidden  drill. 


466     REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL  FILLING 

may  be  sealed  in,  in  the  hope  of  chemically  disintegrating  it.  Milton 
J.  Waas^  recommends  the  application  of  25  per  cent,  aqueous  solu- 
tion of  trichlorid  of  iodin  for  three  minutes  to  form  soluble  ferrous 
iodid  and  chlorid— drying  and  picking  with  Rhein  picks — drilling 
alongside  if  safe,  extending  the  surface  of  application,  repeating  as 
necessary.  For  anterior  teeth  a  coating  of  paraffin  within  coronal 
dentin  to  prevent  discoloration. 

The  head  of  a  Gates-Glidden  drill  or  Kerr  reamer  is  treated  in  the 
same  manner.  Sometimes  in  straight  roots  the  How  applicance 
shown  in  Fig.  453  is  useful.  If  any  broach  be  irremovable,  there  seems 
to  be  no  alternative  except  tentative  treatment  (as  on  page  475)  or 
apicoectomy,  reimplantation  or  extraction. 

The  quality  of  the  Kerr  root  files  together  with  their  taper  renders 
their  use  of  great  advantage  over  barbed  instruments,  though  these 
are  occasionally  useful. 

THE  FILLING  OF  ROOT  CANALS. 

The  opening  of  root  canals  as  described  to  this  point,  leaves  us 
two  conditions  which  have  to  be  considered: 

1.  The  root  canal  has  been  opened  to  the  apical  tissue. 

2.  Such  opening  after  conscientious  work  has  been  found  im- 
possible. 

To  determine  the  success  of  the  operation  a  wire  is  to  be  placed 
in  the  canal  and  a  radiograph  secured.  The  cone  to  be  used,  whether 
of  gutta-percha  or  metal,  may  be  inserted  to  full  penetration  with 
an  aqueous  antiseptic  and  sealed  with  its  lower  end  accessible  for 
removal.  The  radiograph  will  show  the  modifications  necessary. 
This  together  with  the  character  of  the  canal  as  determined  while 
scraping  are  the  only  data  for  guidance  in  root  fillmg. 

The  object  is  to  tightly  seal  the  canal  exactly  to  the  apical  tissue, 
though  it  has  been  determined  that  chloro-percha  and  even  an 
accidentally  extended  gutta-percha  cone  is  not  irritant  after  the  first 
mechanical  disturbance  and  chemical  irritation  from  the  chloroform. 

The  reason  for  complete  filling  is  the  prevention  of  the  presence  in 
any  part  of  the  canal  of  organic  matter,  pulp  remnant,  apical  fluid 
or  fluid  from  the  crown,  which  may  ofPer  nutrient  medium  for  bacteria 
or  any  spaces  that  may  admit  them. 

It  is  here  assumed  that  by  disinfectant  treatment  any  present 
septic  conditions  shall  have  previously  been  removed.  (See  Pulp 
Gangrene,  etc.) 

1  Fully  described  in  Dental  Cosmos,  October,  1918,  and  Dental  Items  of  Interest, 
March,  1918.     Obtainable  from  Merck  &  Co.,  New  York. 


THE  FILLING  OF  ROOT  CANALS  467 

If  possible,  it  is  additionally  desirable  to  so  saturate  the  dentinal 
tubules  opening  into  the  root  as  to  prevent  ingress  of  bacteria  to 
them  or  egress  of  any  accidentally  harbored  in  that  situation. 

Normal  Well-opened  Canals. — ^The  materials  considered  best  for 
the  complete  filling  of  these  are  chloro-percha  and  gutta-percha  cones 
combined  or  a  solution  of  violin  resin  and  giitta-percha  cones. 

ChloTO-percha. — A  s^Tupy  solution  of  gutta-percha  base  plate 
(G.  P.  plus  zinc  oxid)  in  chloroform  which  is  a  disinfectant  in  itself. 
The  writer  prefers  an  addition  of  iodoform  or  aristol  to  maintain 
asepsis  after  the  dissipation  of  the  chloroform,  but  many  prefer  to 
rely  upon  strict  asepsis  only  which  should  be  adhered  to  in  any  case. 
A  small  addition  of  bismuth  trioxid  to  increase  radiopacity  has  been 
suggested  by  Davis^  to  overcome  its  occasional  radiolucency.  Kells^ 
denies  this  but  I  have  certainly  followed  a  gutta-percha  root  filling 
further  than  shown  in  the  radiograph. 

A  further  variant  consists  in  the  use  of  ductile  temporary  stopping, 
which  has  been  melted  in  a  spoon  and  with  which  about  a  fourth  of 
its  bulk  of  aristol  is  incorporated.  These  are  rolled,  under  sterile 
precautions,  on  a  glass  slab  with  a  broad  spatula  to  cone  shape  and 
kept  in  bottles  containing  a  paraform  tablet,  etc.  They  are  more 
readily  compacted  in  canals  than  gutta-percha  cones.  The  writer 
prefers  the  qualities  of  the  S.  S.  White  temporary  stopping  for  this 
purpose. 

Gutta-percha  Cones. — These  are  diagonally  cut  portions  of  gutta- 
percha base  plate  rolled  while  warm  upon  a  slab  with  a  fiat  instrument 
like  an  ivory  paper  cutter  or  broad  steel  spatula.  It  is  well  to  have 
them  quite  long  and  to  flatten  the  larger  end  with  pliers  to  facilitate 
handling  with  pliers  if  desired.  They  are  to  be  kept  in  70  per  cent, 
alcohol  or  10  per  cent,  formaldehyd  solution  or  subjected  to  dichlora- 
mine-T  vapor,  etc.     (See  Asepsis.) 

In  an  experimental  study  of  the  tightness  of  gutta-percha  root 
fillings,  made  mider  exceptionally  favorable  conditions,  and  even  using 
rosin  in  chloroform,  Price^  found  them  not  jto  make  such  a  sealing 
of  canals  as  to  prevent  the  possible  entrance  of  bacteria.  If  they 
are  to  be  used  some  lute  must  be  found  which  shall  better  prevent 
infection. 

While  this  seems  a  laboratory  result  it  is  clinically  a  fact  that  roots 
filled  with  gutta-percha  can  be  handled  for  crown  work  and  bear 
temporary  crowns  set  with  base  plate  gutta-percha  over  quite  a 
period.    Many  roots  partially  filled  give  no  sign  of  abscess  or  granu- 


1  Dental  Cosmos,  May,  1918.  =  Ibid.,  July,  1918. 

5  Journal  National  Dental  Association,  December,  1918. 


468     REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL   FILLING 

loma.    Also  many  granulomas,  etc.,  clear  up  on  proper  sterilization 
and  its  use,  so  that  we  must  await  further  evidence. 

Metal  Cones. — A  variant  in  cones  for  special  purposes  is  a  silver, 
zinc  or  copper  cone  or  sometimes  the  last  Kerr  root  file  used  in 
enlarging  the  canal. 


Fig.  454 


Fig.  455 


Kerr  root  files,  used  as  diagnostic  wm-es 
and  later  as  root  canal  cones. 


Lateral  root  slightly  capped  at  end. 
Cuspid  root  not  completely  filled,  due 
to  root  curve  and  offset  in  canal. 
Amalgam  used  to  repair  a  peculiar 
split,  causing  gingi\atis,  due  to  over- 
hang. 


Fig.  456 


Fig.  457 


Abscessed  right  central,  left  central 
normal  for  years  with  cone  penetrating 
apical  tissue. 


Right  central  fiUed  with  single  cone 
and  chloro-percha,  with  aristol.  Very 
large  inlaj' ,  with  dowel,  due  to  fracture. 
Fresh  pulp  removal. 


The  writer  used  the  Kerr  files  employed  in  scraping  the  roots  in 
the  case  showm  in  Fig.  454.  These  files  remained  in  the  position 
sho\\Ti  for  several  weeks,  while  I  was  ill,  without  irritation.  The 
abscesses  even  improved.  Taking  the  radio  as  a  guide  I  cut^  off  the 
surplus  and  after  pumping  chloro-percha  reintroduced  them  in  their 
respective  roots.  This  was  done  as  a  desperate  experimental  resort, 
the  lingual  root  havmg  pyorrhea  to  the  apex.  Incidentally  this  was 
the  easiest  opened  molar  I  have  ever  treated. 


THE  FILLING  OF  ROOT  CANALS  469 

Colophony. — Callahan  recommends  violin  resin,  grains  12,  in  chloro- 
form 3  drams,  as  a  thm  varnish  for  filling  the  desiccated  tubuli. 
The  canal  is  filled  with  the  solution  and  the  gutta-percha  cone 
pumped  back  and  forth  forty  to  sixty  times  to  dissolve  the  cone  and 
force  the  resultant  mixture  through  the  apical  foramen  and  even 
multiple  foramina.  The  cone,  or  a  fresh  one,  is  then  packed  in  with 
pluggers  touched  to  a  cake  of  paraffin. 

The  cone  is  liable  to  curl  up  under  this  pumping  action  so  that  a 
fresh  cone  might  be  used  after  the  first  few  pumpings. 

When  chloro-percha  is  to  be  used  the  desiccated  tubuli  ma}'  be 
saturated  with  iodoform  in  alcohol,  aristol  in  chloroform  or  mercuric 
chlorid  1  to  500  in  hydrogen  dioxid  or  Callahan's  resin  solution  may 
be  pumped  in  before  applying  the  chloro-percha. 

Crane^  recommends  that  when  it  is  desired  not  to  pass  the  foramen, 
a  small  cone  be  used  with  a  stirring  motion  rather  than  a  pumping 
one  to  get  a  solution,  then  a  larger  but  easy  passing  cone  is  used, 
dipped  in  the  resin  solution  and  passed  almost  to  the  end.  Time  is 
allowed  for  the  chloroform  to  evaporate  and  the  cone  to  soften. 
It  is  then  packed  with  a  blunt  canal  plugger  until  sensation  is  first 
felt. 

A  fine  plugger  is  warmed,  used  to  press  the  cone  laterally,  and  this 
space  then  filled  with  a  cone.  If  incompletely  done  it  is  softened  by 
chloroform  and  repacked  without  removal. 

When  desirable  to  cap  the  root  end,  as  many  cones  as  are  neces- 
sary to  form  sufficient  semifluid  are  used  with  pumping  motion. 
A  cone  is  placed,  allowed  to  soften,  packed  with  the  blunt  plugger  to 
sensation  and  the  patient  allowed  to  bite  on  a  lead  pencil  eraser  to 
force  back  the  soft  filling  solution  around  the  root  end. 

In  the  use  of  chloro-percha  and  cones,  the  former  is  carried  in  on  a 
Kerr  file,  etc.,  and  pumped  down  (or  on  cotton  wound  on  a  Swiss 
broach).  The  cone  previously  tried  for  proper  penetration  and  dried 
is  cut  off  at  say,  a  half  inch  length  and  deposited  in  the  canal  with 
sterile  grooved  pliers  and  pushed  slowly  toward  the  apex  with  the 
largest  admissible  flat-ended  canal  plugger,  followed  by  other  sizes 
until  it  is  packed  solidly  in  the  apical  region. 

If  sensation  is  produced  the  canal  may  be  filled  with  other  sections 
of  the  cone,  each  taking  up  someof  the  chloroform.  If  no  sensation  has 
been  produced  the  remainder  of  the  canal  may  haA'e  a  pellet  of  sterile 
cotton  placed  in  it  and  sealed  in. 

A  radiograph  is  made,  and,  if  necessary,  the  cone  may  be  further 
driven  in  by  malleting  a  canal  plugger  as  suggested  by  Ottolengui. 

1  Dental  Cosmos,  1918,  p.  1C99. 


470     REMOVAL  OF  DENTAL  PULP   AND  ROOT-CANAL  FILLING 

In  large  canals  one  is  liable  to  lose  a  section  of  cone  and  I  prefer 
first  to  try  a  long,  large  tapering  cone,  cutting  off  the  apical  end  if 
sensation  is  produced. 


Fig.  458 


Fig.  459 


Cone  well  placed  at  apex,  with  space 
alongside  at  middle  third.  This  permitted 
passage  of  a  small  broach  for  a  distance. 


Temporarilj^  crowned  central  and  lat- 
eral, with  rarified  apical  tissue.  Cones 
passing  through  toramina.  Cuspid  ab- 
scess, with  fistula  and  consolidated  root 
end  later  drilled  through. 


Fig.  460 


Fig.  461 


Same  as  Fig.  459. 
tissues    improved, 
nient. 


Later  date,    apical 
Formocresol     treat- 


Root  canal  filling,  twenty-one  years 
old,  done  after  incomplete  devitalization 
by  arsenic,  with  slightly  painful  pulp 
removal.    Healthy  apical  tissue. 


Chloro-percha  is  now  pumped  in,  and  the  cone  gently  pressed  in  to 
sensation.  This  is  pressed  aside  and  a  second  cone  introduced,  a 
third,  if  necessary.  The  whole  is  warmed  with  hot  air  and  gently 
packed.    A  single  cone  is  liable  to  leave  a  space  at  its  side. 

Oxychlorid  of  zinc  is  placed  in  the  bulb  of  the  pulp  cavity. 


THE  FILLING  OF  ROOT  CANALS 


471 


Ottolengui^  states  that  chloro-percha,  experimentally  used,  adheres 
to  a  wet  root  apex. 

Some  controversy  exists  as  to  the  passage  of  chloro-percha  out 
of  the  foramen.  It  would  seem  that  the  irritation  produced  subsides, 
the  chloro-percha  becoming  encapsulated  and  tolerated. 


Fig.  462 


Good  old  root  canal  filling.      Xo  history. 
Fig.  464 


Successful  root  filling,  not  goinj 
to  end  of  root. 


Fig.  463 


r 


W 


Gutta-percha  cone  placed  at  eight 
years  of  age.  Twenty-one  years  in 
place  and  comfortable.  Peculiar  ap- 
pearance not  apparently  a  rarefaction. 
Fresh  pulp  removal. 

Fig.  465 


Recent  root  canal  filling  in  slight  excess 
Some  pericementitis  on  treatment  for  pulp 
putrefaction,  some  following  canal  fiUingr 
now  comfortable.  The  bone  in  radio- 
lucent  area  shows  better  than  in  the  re- 
production, which  would  look  like  exten- 
sive abscess.  In  fact,  sensation  was 
produced  bj^  the  chloro-percha. 


Figs.  459  and  4G0  show  the  passage  of  cones  through  the  fojamen, 
probably  to  a  position  rendering  them  irremovable.  A  later  radio- 
gram shows  their  toleration.  Incidentally  these  teeth  were  highly 
infected  open  roots,  repeatedly  treated  with  formocresol  and  tem- 


1  Statement  before  Pennsylvania  State  Dental  Society,  1917. 


472     REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL   FILLING 

porarily  crowned  for  weeks.  These  roots  are  comfortable  at  present 
with  porcelain  faced  crowns  mounted  on  them.  The  fistula  on  the 
cuspid  has  healed.     Fistulas  rarely  show  well  in  radiographs. 

Euca-percha. — The  basis  of  this  substance  is  a  solution  of  gutta- 
percha base-plate  in  eucalyptol.  To  this  various  antiseptics  may 
be  added.  There  are  various  modes  of  making  this  substance. 
B.  L.  Cochran^  suggests  the  following: 

I^ — Gutta-percha  base-plate gss 

Dissolve  in  chloroform  q.  s.  to  a  thin  solution. 

Add  saturated  solution  of  thymol  in  eucalyptol    .      .      .     fgss 
Let  the  chloroform  evaporate. 

Euca-percha  Compound  (Buckley,  Lilly)  is  a  simple  solution  of 
base-plate  in  eucalyptol  made  by  aid  of  heat. 

Formo-percha  (Blair)  has  paraform  and  oil  of  cassia  added. 

This  material  may  be  warmed  into  a  creamy  paste  and  be  used 
either  on  cotton  or  be  used  in  conjunction  with  gutta-percha 
cones. 

Oxychlorid  of  Zinc- — The  use  of  oxychlorid  of  zinc  cement  pumped 
into  the  root  has  long  had  a  value.  The  zinc  chlorid  is  antiseptic. 
The  chief  objection  lies  in  its  being  a  cement  which  is  always  difficult 
to  introduce  against  the  air  column,  i.  e.,  the  filling  is  apt  to  be 
imperfect. 

Custer  proposes  a  novel  method.  "A  long  zinc  cone  is  used  to  intro- 
duce oxychlorid  of  zinc  with  which  precipitated  metallic  zinc  has  been 
incorporated  to  make  it  a  conductor  of  electricity  in  future  treat- 
ments by  electrolysis  if  needed."  While  described  for  the  treatment  of 
infected  roots  after  electrolytic  treatment  (see  Pulp  Gangrene),  it 
should  have  a  value  if  it  can  be  shown  to  be  effective.  The  oxychlorid 
is  pumped  in  and  the  zinc  cone  left  in  and  cut  off  in  the  pulp  cavity 
in  an  accessible  position.  According  to  Custer's  idea  if  granuloma 
recurs  the  zinc  cone  is  to  be  uncovered  and  galvanic  electricity  applied. 

Roots  with  Open  Foramina.— These  may  be  incomplete  roots  with 
very  large  apical  openings,  in  which  case  wax  with  aristol  is  the  best 
filling  used,  as  previously  stated.  It  should  be  said  again,  however, 
that  if  possible  the  pulp  of  such  a  tooth  should  be  capped  to  permit 
root  formation  to  be  completed. 

If  the  foramen  is  of  moderate  extent  and  either  natural  or  unfor- 
tunately made  with  drills,  gutta-percha  cones  are  valuable. 

A  long,  tapering  cone  is  prepared.  Some  point  on  this  must  fit 
the  foramen.  It  is  tried  in  and  as  often  as  sensation  is  felt  it  is 
cut  off  a  trifle  and  tried  again  until  it  chokes  the  foramen  without 
sensation. 


THE  FILLING  OF  ROOT  CANALS 


473 


In  case  of  abscess,  or  even  in  fresh  pulp  removals,  this  may  extend 
beyond  the  apex  of  the  tooth. 

The  cone  should  be  marked  at  a  point  corresponding  to  a  guide 
point  chosen  and  be  laid  aside.  Next,  a  fine  hook  made  by  bending 
the  tip  of  a  fine  broach  to  a  right  angle,  then  cutting  it  close  to  the 
shank,  has  a  piece  of  rubber  dam  slipped  over  it  and  is  passed  through 
the  apex  and  hooked  upon  the  edge  (Fig.  466) .  The  dam  is  slipped 
to  the  chosen  guide  point.  The  probe  hook  is  withdrawn,  the  dam 
laid  at  the  mark  on  the  cone,  and  the  cone  cut  off  at  the  lower  edge 
of  the  hook  (Fig.  466,  h) .  It  should  be  firmly  placed  or  even  sealed  in 
position  with  the  end  accessible  and  radiographed.  The  protruding 
end  is  cut  off.  In  use,  a  little  solvent,  preferably  chloro-percha  plus 
aristol,  is  placed  in  the  canal  and  the  cone  slowly  slipped  to  place 
until  the  mark  coincides  with  the  guide  point.  The  cone  is  then  cut 
off  with  a  hot  instrument,  warmed,  and  gently  packed  into  the  canal. 
A  section  may  be  used.     Fig.  463  is  from  a  case  so  treated. 


Fig.  466 


Fig.  467 


Manner  of  measuring  the  length  of  a  root 
and  fitting  a  gutta-percha  cone. 


fwm 

Manner  of  tapering  a  canal  to  fit 
cone  of  the  same  size. 


When  the  canal  has  been  reamed  with  a  small  engine  reamer,  and 
the  apex  enlarged,  thus  having  parallel  sides,  it  is  advisable  to  make 
it  cone  shaped.  The  hook  may  be  placed  and  have  a  bit  of  rubber 
dam  on  it  as  a  guide.  Then  slip  a  bit  of  dam  over  a  larger  tapering 
root  reamer  at  a  corresponding  length.  Drive  the  reamer  in  until  at 
the  guide  point.  The  cone  is  then  constructed  as  above  described. 
(Fig.  467). 

In  some  cases  of  large  foramina  or  perforation  a  bit  of  sterile 
grafting  sponge  may  be  introduced  into  the  apical  space  and  the 
filling  placed  against  it.^    This  has  not  been  tested  by  radiography. 


1  G.  Brunton,  England:  Dental  Cosmos,  1900. 


474     REMOVAL  OF  DEXTAL  PULP    AXD   ROOT-CAXAL   FILLIXG 

Wax  or  Paraffin. — Either  of  these  may  have  a  portion  of  thymol, 
aristol,  or  iodoform  added  to  it  while  melted  in  a  spoon.  It  is 
then  rolled  into  cones.  In  use  a  cone  is  dropped  into  the  dried  pulp 
chamber  and  a  hot  Evans  root  drier  point  applied.  As  it  melts,  the 
metal  point  is  carried  down  into  the  root  and  the  fluid  material 
pumped  to  the  apex.  Capillarity  does  part  of  the  work.  It  adjusts 
itself  to  the  tissue  and  the  canal  walls.  The  pulp  chamber  is  then 
cleared  of  excess  wax,  etc.,  and  filled  without  pressure. 

Prinz^  recommends  the  use  of  hard  paraffin  having  a  melting 
point  of  not  less  than  132°  F.  in  the  following  combination: 

I^— Thymol '    2  parts 

Bismuth  trioxid 30  parts 

Hard  paraffin 68  parts 


Fig.  468 


Fig.  469 


A,  perforation  through  side  of  apex; 
D,  cone  of  gutta-percha  passing  through. 


Lateral  perforation  due  to  holding  a 
bur  at  a  wrong  angle  to  the  axis  of  the 
root:  A,  root  canal  subsequently  filled 
with  gutta-percha;  B,  perforation  filled 
with  a  fitted  cone  of  gutta-percha;  C, 
zinc  oxy-chlorid. 


The  canal  is  to  be  thoroughly  dried,  then  merely  moistened  with 
liquid  paraffin,  a  cone  of  the  compound  then  to  be  placed  in  the 
canal  and  melted  with  a  root  drier  (an  electric  drier  or  Evans'  or 
Reithmiiller's  modification,-  Fig.  393).  The  paraffin  combines  with 
it  and  leads  it  to  place  with  exclusion  of  air.  The  bismuth  is  added 
to  make  it  impervious  to  the  a--rays,  hence  it  throws  a  radiographic 
shadow. 

The  paraffin  seems  occasionaUy  to  disappear  from  canals.  Dr. 
Edwin  Shoemaker  demonstrated  one  case  in  which  a  root  shown  well 
filled  with  paraffin  in  one  radiograph  had  apparently  lost  a  con- 
siderable portion  as  shown  by  a  succeeding  radiograph.  To  what 
extent  this  is  true  as  also  claimed  by  Reithmiiller^  is  not  kno-^ii  nor 

1  Dental  Cosmos,  October,  1912,  p.  1089.  =  Ibid..  March,  1913,  p.  342. 

3  Not  published  in  his  paper  in  Dental  Cosmos,  May,  1917,  but  shown  at  Academy 
of  Stomatologj'. 

*  Private  Communication. 


THE  FILLING  OF  ROOT  CANALS  475 

Is  it  certain  whether  it  is  an  absorption  or  a  case  of  original  non- 
placement.  Reithmiiller  claims  that  the  radiograph  demonstrated 
good  filling,  but  that  subsequently  it  had  disappeared.  In  Shoe- 
maker's case  there  was  no  e\'idence  of  tissue  entering  the  root  canal. 
In  my  use  of  wax  plus  thymol  I  have  later  found  canals  unfilled  at 
the  apical  end.    I  believe  the  air  cushion  makes  the  difficulty. 

Salol  and  Thymol. — Both  these  sohd  antiseptics  melt  above  body 
temperature  and  should  theoretically  be  perfect  root  fiUmgs  when 
melted  in  roots.  They  are  subject  to  disappearance  as  above  noted, 
with  paraffin.  The  WTiter  tried  thymol  with  cotton  to  be  certain  of 
placement,  but  later  the  cotton  was  found  limp  and  easily  removable 
with  a  barbed  broach. 

Silver  Deposition.^Howe  claims  that  an  insoluble  silver  deposition 
may  be  deposited  in  apical  deltoid  or  fine  inaccessible  foramina.  The 
method  is  described  in  full  on  page  477. 

Inoperable  Apices. — ^\'arious  remedies  for  multiple  foramina  have 
been  suggested. 

1.  The  method  of  Callahan,  pumping  thin  \'iolin  resin  solution, 
the  chloroform  of  which  also  dissolves  the  gutta-percha  creating  a 
mixtm*e.    This  has  just  been  referred  to  (page  469). 

2.  Malleting  the  cone  upon  chloro-percha  previously  introduced 
to  force  it  sidewise  if  the  foramina  happen  to  be  lateral. 

Fig.  411  shows  multiple  foramina  considered  by  Callahan  to  be 
present  in  a  large  percentage  of  molars. 

3.  Filling  solidly  with  gutta-percha  and  chloro-percha  to  the  part 
or  with  oxychlorid  of  zinc  and  a  cone  of  gutta-percha  (Prinz)  and 
subsequent  apicoectomy  (q.  v.). 

4.  Extraction,  root  filling,  exsection  of  the  root  end  and  reimplan- 
tation. 

5.  The  use  of  iodoform  paste,  oxpara,  mummifying  paste  or  similar 
substance  packed  alone  or  in  connection  wdth  a  cone  of  gutta-percha. 

6.  The  Howe  Treatment  and  Filling.     (See  page  477.) 

7.  Extraction  as  incurable  (especially  in  abscess  cases.) 

These  methods,  with  perhaps  the  exception  of  apicoectomy,  may 
be  considered  sub  judice  with  much  disfavor  shown  them  particularly 
as  to  use  of  pastes. 

Grieves^  makes  the  statement  that  his  radiographic  observations 
show  that  such  cases  as  have  had  mummifying  pastes  used  have 
very  infrequently  showai  granulomas.  He  disclaims  advocacy  of  the 
practice.  Hundreds  of  radiographs  showing  canals  only  partly  filled 
with  gutta-percha,  etc.,  show  no  granulomas. 

1  Journal  of  National  Dental  Association.  1917,  p.  167. 

2  Ibid.,  August,  1918.  p.  788. 


476      REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL  FILLING 

It  would  seem  fair  that  this  subject  should  be  threshed  out  by 
carefully  conducted  cases  before  the  method  should  be  condemned 
m  this  class  of  cases,  especially  if  kept  under  radiographic  observa- 
tion.    (See  Mummifying  Pastes.) 

The  Howe  method,  of  infiltrating  the  multiple  foramma  and  tubuli 
with  a  sterilizing  silver  deposit  seems  w^orthy  of  extended  experi- 
mentation. 

Fig.  470 


Levy's  pulp  canal  pluggers. 


Canal  Pastes. — The  pastes  which  I  have  used  are  iodoform  paste 
and  mummify mg  pastes.  I  am  not  able  to  certify  to  the  status  of 
these  materials,  but  believe  their  use  is  occasionally  justified  in  molars. 

Iodoform  Paste. — To  a  resinous  solution  (made  by  adding  resin  to 
formocresol  and  removing  the  water  which  separates),  iodoform  and 
bismuth  subnitrate  or  trioxid  may  be  added.  The  thin  solution  or 
cresol  alone,  is  first  pumped  in  to  exclude  air.  Then  thick,  freshly- 
made  paste  is  gradually  pumped  dovra  and  the  whole  compressed 
with  cotton  to  absorb  the  moisture  and  either  left  in  that  condition 
or  a  cone  of  gutta-percha  introduced.  Oxyeugenol  plus  aristol,  then 
a  cone,  is  commended  by  Howe  after  his  silver  treatment,  but 
iodoform  may  be  substituted. 

Mummifying  Paste. — There  are  several  formulae  for  this: 

I^ — Paraform 1  part 

Thymol 1  part 

Glycerin 1  part 

Zinc  oxid 1  part  or  more. 

Or, 

I^ — Paraform 1  part 

Thymol .'      .      .  2  parts 

Alum 1  part 

Zinc  oxid 2  parts 

Creosote  to  a  thick  or  thin  paste. 


THE  FILLING  OF  ROOT  CANALS      '  477 

This  is  used  as  a  temporary  germicidal  canal  dressing  on  cotton 
or  as  a  root-filling  with  gutta-percha  or  temporary  stopping  cones 
which  are  pressed  into  it. 

Fig.  471 


Root-canal  filling:  A,  gutta-percha;   B,  zinc  oxychlorid. 

Soderberg^  recommended  a  paste  composed  as  follow- s : 

^ — Alum  exsic, 
Ths'mol, 

Glycerol aa     3J 

Zinci  oxidi        ........     q.s.  to  make  a  stiff  paste — M. 

It  is  preferable  to  add  the  zinc  oxid  as  needed  or  to  make  a  small 
quantity  of  the  paste  frequently,  as  it  gradually  hardens.  To  the 
paste  used  a  crystal  of  cocain  is  added  to  prevent  pain.  Bennette,  of 
England,  has  advised  the  use  of  paraform  incorporated  in  the  paste, 
for  its  well-known  antiseptic  and  hardening  effects.  Greenbaum 
suggested  the  use  of  a  drop  of  40  per  cent,  formaldehyd  solution  to  be 
incorporated  with  the  paste.  Both  reduce  the  pulp  to  the  consistence 
of  catgut. 

Soderberg  reopened  cases  months  after  application  of  the  paste  to 
pulp  stumps,  and  found  them  shrunken  and  with  an  odor  of  thymol 
about  them.  It  is  not  recommended  to  use  this  other  than  as  a 
canal  filling. 

These  would  be  used  as  antiseptic  pastes  in  all  cases  and  addi- 
tionally as  mummifying  agents  in  inoperable  apices  containing  a 
vital  filament  of  pulp. 

All  such  cases  should  be  provisionally  filled  "^-ith  the  understanding 
that  extraction  is  to  be  resorted  to  if  granuloma  arises. 

Howe  Method.--Howe's  method  of  infiltrating  apical  deltoid  or 
fine  inoperable  foramina  has  aroused  much  interest.  It  aims  at  a 
deposit  of  silver  within  the  tubules  and  in  such  fine  canals,  filling 
them  with  a  mirrorlike  deposit.  Howe's  claim  of  canal  sterility  is 
endorsed  by  Price  and  Brooks. 

1  Dental  Cosmos,  November,  189g, 


478     REMOVAL  OF  DENTAL  PULP  AND   ROOT-CANAL   FILLING 

Two  solutions  are  used: 

Solution  A. 

Silver  nitrate •    . ^3       grammes. 

Water '  1      mil. 

Aqua  ammoniEe  fortior         2.5  c.c. 

The  silver  nitrate  is  first  dissolved  in  the  water  and  the  ammonia 
added  gradually  till  a  black  precipitate  is  formed  and  redissolved. 

Solution  B. 

Liquor  formaldehydi  (formalin) 1  part. 

Water 3  parts. 


Making  a  10  per  cent,  solution. 

Fig.  472 


Fig.  473 


Showing  it  to  be  possible  to  use  this  Illustrating  the  manner  in  which  the 

method  in  anterior  teeth.     No  discolora-      solution  finds  its  way  to  the  very  end  of 
tion  of  crown.    (Howe.)  the  root,  even  when  the  broach  is  unable 

to  reach  it.    (Howe.) 

The  interior  of  the  cavity  and  pulp  cavity  is  coated  with  sticky 
wax  (or  a  cavity  varnish).  This  is  perforated  with  a  cold,  wet  instru- 
ment. Solution  A  is  run  in  with  a  smooth  broach,  gently  raised  and 
lowered.  A  drop  of  Solution  B  is  added  and  run  in  allowing  a  few 
minutes.  This  is  absorbed  and  the  process  repeated  three  times. 
The  canal  is  then  dried  by  absorption  and  Solution  A  is  applied 
alone  to  remove  all  formaldehyd.  This  is  followed  by  eugenol, 
which  in  recent  extirpations  is  dried  out  and  the  canal  filled.  (Howe 
employs  aristol  zinc  oxid  and  eugenol  paste  with  a  gutta-percha  cone.) 


THE  FILLING  OF  ROOT  CANALS  479 

In  septic  cases  the  eugenol  is  sealed  in  and  the  process  repeated 
at  a  second  sitting  at  which  the  canal  is  filled.  (See  Figs.  472 
and  473.) 

Root  Canals  in  Temporary  Teeth. — The  difficulty  in  temporary 
molars  which  are  the  ones  usually  treated  is  their  resorbed  root  ends. 
Probably  paraffin  and  aristol  or  Prinz's  paraffin  root  filling  meets  the 
indication  best,  as  a  resorbable  material  is  desirable. 

Buckley  recommends  in  cases  of  chronic  abscess  the  use  of  a  stiff 
mixture  of  calcium  phosphate  and  formocresol  (formalin,  1  part; 
cresol,  2  parts),  to  be  packed  into  the  pulp  cavity  and  zinc  phosphate 
flowed  over  it. 

Johnson  recommends  euca-percha  to  be  pumped  into  the  canals 
and  pressure  with  temporary  stopping  to  be  exerted  until  the  solution 
appears  at  the  fistula.  Such  temporary  stopping  as  does  not  interfere 
with  filling  integrity'  should  be  left. 

Root  Canal  Filling  Coverings. — Having  radiographed  the  root  to 
ascertain  if  the  filling  is  satisfactory,  the  covering  may  consist  of 
temporary  stopping  plus  a  trifle  of  thymol  or  oxychlorid  of  zinc  to 
prevent  infection  and  discoloration.  This  may  occupy  the  pulp 
chamber  unless  anchorage  therein  is  necessary. 

Pulp  Digestion. — Harlan  recommended  that  the  following  paste  be 
applied  to  unremoved  portions  of  dead  pulps  as  a  means  of  digesting 
them  preparatory  to  root  filling: 

I^ — Papain         gr.  v 

Price's  pure  glycerin TTliv 

Sol.  1  to  200  hydrochloric  acid mv— M. 

This  is  applied  in  the  pulp  canal,  covered  with  blotting  paper 
soaked  in  liquid  vaselin,  and  the  whole  temporarily  sealed  for  a  few 
days.  The  pulp  is  reduced  to  the  consistence  of  jell}^  and  can  be 
readily  washed  out.    It  might  be  of  use  in  an  impasse. 

The  Filling  of  Perforations. — Perforations  made  high  up  in  the  canal,, 
after  being  appropriately  sterilized  with  formocresol,  should  be  filled 
with  gutta-percha  cones  and  chloro-percha,  and  the  apex  amputated. 

In  low  perforations  without  a  fistula  associated,  the  opening  of 
the  perforations  should  be  enlarged  inwardly  and  a  ball  or  plaque  of 
aseptic,  warm,  low-heat  gutta-percha,  or  even  temporary  stopping, 
adapted  to  the  opening.  A  piece  of  pure  gold  plate  may  be  burnished 
over  an  accessible  opening,  and  be  adapted  with  thick  chloro-percha 
or  temporary  stopping.  Any  of  these  may  be  fixed  in  place  with 
oxyphosphate  of  zinc.  Quick-setting  oxyphosphate  of  copper  in  its 
soft,  gummy,  state  may  be  painted  over  the  tissue  and  root  opening 
by  means  of  an  instrument,  or  the  perforation  may  often  be  satis- 
factorily closed  with  copper  amalgam.    When  in  posterior  teeth  a 


480     REMOVAL  OF  DENTAL  PULP   AND  ROOT-CANAL  FILLING 

pin  must  be  used,  the  pin  may  be  made  smaller  than  the  root  canal 
and  be  coated  with  wax,  soft  oxyphosphate  of  copper  is  put  in  the 
canal,  and  the  pin  gently  thrust  in.  When  the  cement  has  set  the 
pin  may  be  heated  and  withdrawn,  and  when  included  in  the  intended 
superstructure,  the  pin  may  be  again  cemented  in  place  (see  Figs. 
325,  and  328). 

When  a  perforation  threatens  to  produce  an  abscess  an  artificial 
fistula  should  be  made  and  the  case  treated  accordingly. 

If  a  perforation  have  a  fistula  associated  with  it,  the  oxyphosphate 
of  copper  or  zinc  oxychlorid  may  be  allowed  to  go  through  the  fistula, 
by  way  of  which  any  excess  may  be  removed.  In  some  accessible 
cases  I  have  even  used  local  anesthesia,  cut  down  upon  the  perforation, 
packed  the  artificial  fistula  open,  prepared  as  for  a  small  filling  and 
filled  with  amalgam,  polishing  on  the  following  day.  The  tissue  seems 
to  heal  over  the  filling.  These  suggestions  are  subject  to  radiographic 
findings  both  before  and  after  filling  and  may  in  future  prove  inadvis- 
able.   (See  Granuloma,  Chronic  Abscess,  etc.) 


CHAPTER  XV. 
GANGRENE  OF  THE  PULP. 

Gangrene  signifies  a  form  of  necrosis  of  tissue  en  masse,  which  has 
been  caused  by  interference  with  its  circulation.  Thus  an  entire  toe, 
a  large  portion  of  leg,  a  tooth  pulp  dying  through  a  cessation  of  nutri- 
tion due  to  circulatory  disturbance  is  gangrenous  at  the  moment  of 
its  complete  death  regardless  of  its  subsequent  mummification  or 
putrefaction  which  are  the  two  results.    (See  page  51.) 

In  general  the  gangrene  is  either  due  (1)  to  arterial  obstruction, 
e.  g.,  thrombosis  of  the  femoral  artery  causing  ischemia  of  the  leg 
and  subsequent  death  from  lack  of  nutrition,  a  condition  only  pos- 
sibly due  in  the  pulp  to  apical  obstruction  by  closure  of  the  apical 
foramen  or  to  embolism  of  the  pulp  artery  (infarction) .  In  such  case 
the  part  is  dry,  reasonably  aseptic  and  generally  mummifies.  (2)  To 
venous  obstruction,  producing  profound  venous  liAperemia,  nutrition 
ceasing  after  available  food  supply  is  exhausted ;  death  resulting.  This 
is  the  common  condition  found  in  spontaneous  pulp  death,  owing 
to  the  anatomical  peculiarity  that  the  pulp  is  boxed  in  the  pulp 
chamber  and  compression  of  the  vein  by  the  artery  leads  to  venous 
h>i)eremia.     (See  page  392.) 

Though  such  a  pulp  usually  putrefies,  there  may  be  a  period  as 
when  a  pulp  dies  by  venous  hj'peremia  from  thermal  shock,  during 
which  there  is  no  infection.  This  is  a  true,  piu-e  moist  gangrene,  as 
the  pulp  is  full  of  blood  and  fluid. 

There  are  other  forms  of  pulp  death  possible,  e.  g.,  progressive 
ulceration,  but  the  writer  believes  that  whatever  the  irritant  at  the 
pulp  bulb,  chemical  or  mechanical  irritation  or  infection  producing 
inflammation,  thermal  shock  inviting  arterial  blood  (arterial  hyper- 
emia), inflammation  or  hj'peremia  of  apical  tissue,  causing  a  sec- 
ondary arterial  hyperemia,  or  the  irritation  of  arsenic,  there  is  always 
first  arterial  h\T)eremia,  followed  by  venous  hj^Tperemia  in  the  remam- 
ing  tissue  before  its  death,  en  masse.  That  this  may  be  but  a  partial 
venous  hj^jeremia  accounts  for  the  persistent  vitality  in  many  cases. 
The  pulp  usually  dies  first  at  the  bulb  in  nearly  every  case,  but  this 
is  but  the  natural  effect  of  stagnation  of  blood  prevented  from 
escaping,  at  least  partly,  from  the  somewhat  compressed  vein,  while 
the  enlarged  artery  compressing  it  brings  an  excess  of  blood.  If  the 
compression  should  be  profound  total  death  would  rapidly  ensue. 
31  (481 ) 


482  GANGRENE  OF  THE  PULP 

As  in  every  case  of  gangrenous  pulp,  the  pulp  tissue  either  dries 
into  a  shrivelled  mass  or  putrefies,  we  have  the  conditions  dry 
gangrene  or  pulp  mummification  and  moist  gangrene  or  pulp  putre- 
faction;  these  being  the  terms  employed  by  general  pathologists. 

DRY  GANGRENE  OF  THE  PULP   (PULP  MUMMIFICATION). 

Definition.— By  dry  gangrene  of  the  dental  pulp  is  meant  its  death 
in  toto  and  its  subsequent  transformation  into  a  dry,  shrivelled  mass 
occupying  the  pulp  chamber  and  canal. 

Causes  and  Pathology. — If  the  pulp  die  and  remain  under  conditions 
which  exclude  bacteria  from  contact  with  it,  the  water  of  the  pulp 
may  be  removed,  leaving  the  organ  as  a  tough,  shrivelled  mass  (Fig. 
474).    The  conditions  most  favorable  seem  to 
Fig.  474  ]-,g.     Q^  Pulp  death  from  some  aseptic  cause, 

e.  g.,  the  hyperemia  resulting  from  a  blow  on  a 
sound  tooth;  (2)  constriction  of  the  apical  fora- 
men, due  to  hypercementosis,  the  result  of  thread 
biting  or  other  mild  irritation  of  the  pericemen- 
tum; (3)  the  presence  of  secondary  dentin  over 
the  bulbar  portion  of  the  pulp,  causing  pulp  ex- 
haustion yet  protecting   it  from  infection;  (4) 
Dry  gangrene  of  the     the  Capping  of  the  pulp  with  ziuc  oxychlorid  or 
P^jP;  ^^'  p^!p  ^°"     formagen  paste,  the  pulp  being  permeated  with 
pulp'.    (From  a  sped-    '  the  drug  or  dried  by  it;  (5)  the  covering  of  pulp 
men  of  pulp  extracted     -gtumps   with   a  pastc  Containing  a  tannif  ying 

intact     m    this    con-  ,  ^  o  ^  ^   ^       ^ 

dition.)  substance,    such    as    alum,    lormaldehyde,     or 

tannin. 

The  water  necessary  to  putrefaction  is  abstracted,  either  naturally 
or  chemically,  and  probably  bacteria  are  at  the  same  time  excluded, 
either  mechanically  or  because  the  chemical  substances  used  have 
penetrated  the  pulp  tissue,  acting  as  antiseptics. 

Symptoms. — -The  tooth  has  a  nearly  normal  color,  but  under  a 
reflected  light  is  seen  to  have  lost  perfect  translucency.  There  is  no 
response  to  thermal  or  electric  tests  for  pulp  vitality.  The  dentin  is 
insensitive  to  cutting  instruments,  and  the  cuttings  upon  the  bur 
have  no  odor.  There  is  no  odor  or  fluid  in  the  pulp  canal  when  this 
is  entered,  and  the  pulp  is  found  as  a  tough,  dry  mass  not  unlike 
that  seen  in  a  dry  extracted  tooth  which  contained  a  vital  pulp  at 
the  time  of  extraction.  These  cases  as  spontaneous  occurrences  are 
relatively  rare. 

Treatment. — If  septic  matter  be  introduced  a  violent  pericementitis 
may  be  lighted  up;  but  if  aseptic  precautions  be  employed  in  opening 


DRY  GANGRENE  OF  THE  PULP 


483 


the  canal,  and  this  be  kept  under  the  influence  of  a  germicide,  such 
as  5  per  cent,  formaldehyde,  the  root  may  be  filled.  A  dressing  of 
modified  formocresol  may  be  introduced  for  a  time  and  the  root  then 
filled.  The  case  should  be  radiographed  for  possible  apical  granu- 
loma. No  available  record  of  a  granuloma  exists  as  these  cases  may 
Yery  rarely  be  seen. 

A  temporary  filling  of  pink  base-plate  gutta-percha  is  to  be  inserted 
in  the  crown  cavity  until  all  irritation,  if  any,  subsides. 

Slight  aseptic  apical  irritation  may  be  anticipated  as  a  matter 
of  precaution  by  the  use  of  iodin  as  a  counterirritant  at  the  time 
of  root  filling  (see  page  391).  Such  irritation  is  either  mechanical  or 
due  to  the  chemical  substances  used. 

Tests  for  Pulp  Vitality.— The  diagnosis  of  pulp  vitality  or  death 
being  in  practice  almost  daily  requhed,  the  tests  are  here  indicated. 
Some  of  these  are  decisive  when  used  and  no  other  need  be  used. 
Again  several  tests  may  be  needed.  Even  radiography  is  not  always 
decisive. 


Fig.  475 


Fig.  476 


Two  vital  teeth  so  found  on  drilling 
(see  text) . 


Vital  bicuspid,  showing  non-septic 
pericementitis  due  to  overwork  (see 
text). 


1.  Sensitivity  of  dentin  upon  cutting,  touching  a  tooth  neck,  re- 
sponse to  such  remedies  as  absorb  water^ — glycerin,  potassiiun  carbon- 
ate, zinc  chlorid,  etc.  (see  page  324),  are  evidences  of  vitality.  Lack 
of  response  is  not  a  final  test  of  death,  but  must  be  supplemented  by 
other  tests.  Thus  a  cavity  may  sometimes  be  nearly  prepared  with- 
out sensation,  but  on  drilling  a  retention,  a  last-procediue  sensation 
is  produced.  It  is  decisive  if  characteristic.  Thus  in  Fig.  475  drilling 
toward  a  pulp  in  the  bicuspid  suspected  of  death  established  its 
vitality  as  did  drilling  through  the  crown  on  the  molar.  The  molar 
crown  was  removed  on  suspicion  of  septic  cement  because  of  suspicion 
that  it  acted  as  a  cause  of  systemic  depression.  Excavation  for  a 
filling  on  the  side  of  the  crowned  bicuspid  in  Fig.  476  gave  the  same 
result. 


484  GANGRENE  OF  THE  PULP 

2.  A  tootli  containing  a  vital  pulp  is  translucent  and  pink;  that 
containing  a  dead  one  always  opaque  to  transmitted  light  even  when 
it  looks  normal  to  the  eye,  and  usually  clouded  to  a  gray  or  bluish- 
black,  though  sometimes  yellow  or  brown.  The  ordinary  appearance 
by  reflected  light  often  corresponds  to  this,  but  sometimes  a  tooth  is 
clouded  by  fillings,  or  looks  dead,  but  is  vital.  In  such  case  the 
cervix  may  show  normal  translucency.  In  one  case  of  neuritis  a 
search  for  devital  teeth  was  instituted.  A  molar  with  clouded  cervix 
was  suspected  and  electrical  test  proposed,  but  on  casual  exploration 
a  sensitive  neck  was  discovered.  This  being  test  No.  1  was  decisive 
of  vitality. 

An  electric  mouth  lamp  with  or  without  a  reflector  so  arranged  as 
to  reflect  the  light  upon  the  lingual  surface  of  the  tooth  M'ill  supply 
the  means  for  this  test.  In  its  absence  strong  sunlight  may  be 
reflected  by  means  of  a  mouth  mirror,  but  is  not  nearh^  so  good  a 
means  as  the  electric  light  (Fig.  309). 

3.  A  strong  odor  of  putrefaction  may  be  obtained  from  bur  cuttings 
in  cases  of  moist  gangrene  only.  This  must  be  differentiated  from 
the  odor  of  decayed  dentin,  which  usually  also  has  an  acid  character. 
In  case  of  partial  death  of  the  pulp  not  discoverable  by  the  test 
given  above,  a  fine,  sharp  probe  passed  into  contact  with  the  pulp 
remnant  will  demonstrate  its  vitality  or  death. 

4.  If  the  tooth  be  isolated  by  means  of  rubber  dam  and,  first,  cold 
water  be  thrown,  or,  later,  ethyl  or  methyl  chlorid  be  sprayed  upon 
it  or  upon  the  filling  contained  in  it,  or  a  pointed  bit  of  ice  be  applied 
to  the  tooth  or  a  filling,  absence  of  response  will  indicate  either  par- 
tial or  total  pulp  death  or  the  formation  of  a  quantity  of  secondary 
dentin.  In  the  latter  case  the  test  must  be  renewed  as  the  excavation 
proceeds.  Degeneration  of  the  pulp  may  be  thought  of,  but  pulps 
need  not  be  removed  because  of  such  suspicions  unless  other  sjTiiptoms 
demand  it. 

A  burnisher  heated  in  the  flame  or  a  gutta-percha  heater  (electric), 
or  hot  copper  ball  or  hot  gutta-percha  applied  to  a  filling  or  dentin, 
or  very  hot  water  thrown  upon  an  isolated  tooth,  should  provoke  at 
least  a  delayed  response  from  a  vital  pulp. 

This  test  is  positive  for  vitality  if  the  tooth  responds  vigorously, 
but  should  be  coupled  with  other  tests  if  no  response  is  obtained. 
Isolation  by  dam  or  tilting  back  the  head  and  testing  first  posteriorly 
then  progressing  fol■\^^ard,  are  the  best  means  of  localizing  the  test 
(see  test  for  arterial  hyperemia). 

5.  The  application  of  a  small  high  frequency  glass  electrode  (violet- 
ray)  to  the  enamel  of  a  vital  tooth  produces  a  peculiar  sensation  not 
unlike  that  of  hypersensitive  dentin.     It  is  due  to  the  fact  that  the 


DRY  GANGRENE  OF  THE  PULP 


485 


enamel  is  like  glass  unable  to  insulate  the  high  frequenc}'  current 
which  passes  to  the  dentinal  fibril.  A  devitalized  tooth  will  not 
respond.  The  facility  of  this  test  makes  the  apparatus  a  very  valu- 
able  time  saver  in  anterior  teeth.  Jmnping  of  the  current  from  the 
side  of  the  tube  necessitates  care  in  posterior  teeth.  It  may  confuse- 
if  it  jumps  to  the  gum.  It  is  well  to  take  up  the  current  with  the 
finger  on  the  side  of  the  tube  at  first  and  to  raise  the  finger  after  the 
glass  is  in  contact  with  the  tooth.     (See  Uses  of  Electricity.) 


Fig.  47 


Faradic  battery. 


The  electrodes  described  in  the  text  should  be  substituted  for  those 
shown. 


Woodward  has  shown  that  if  a  few  cells  of  a  cataphoric  apparatus 
(also  ionization  apparatus)  are  in  action  and  the  positive  electrode 
be  applied  to  the  dentin  or  metal  fiUmg  in  a  vital  tooth,  while  the 
negative  pole  is  at  the  cheek  or  wrist  of  the  patient,  a  distinct  sensa- 
tion should  be  felt,  while  in  case  of  a  dead  pulp  there  will  be  no 
response;  usually  even  a  small  filling  will  transmit  a  distinct  shock 
in  a  vital  tooth  which  is  absent  in  a  devitalized  tooth.  A  mild  inter- 
rupted current  was  suggested  by  Marshall  and  is  a  valuable  test. 
A  helix  or  an  ordinary  Faradic  battery  may  be  used.  The  batteries 
bought  serve  a  current  that  is  satisfactory  if  applied  to  the  enamel 
through  which  the  shock  may  be  felt,  but  is  too  strong  if  applied  to 


486  GANGRENE  OF  THE  PULP 

fillings  or  dentin.  The  test  upon  the  tooth  exterior  is  sometimes 
best,  as  when  there  is  no  filling  or  it  extends  to  the  gum  which  is  a 
confusing  factor,  but  sometimes  it  is  difficult  to  get  response,  while 
a  filling  will  allow  it,  though  curiously  one  filling  may  permit  the  test 
while  another  may  not.  The  electrode  may  be  covered  with  wet 
cotton  and  carried  to  the  enamel,  about  over  the  pulp  being  the  best 
point  for  response.  If  desired  to  test  via  the  filling,  it  is  best  to  use 
an  electrode  containing  water  resistance.  This  is  easily  made  by  the 
use  of  a  glass  tube  corked  at  either  end.  Through  each  cork  is  run 
a  bit  of  brass  or  copper  w^ire.  One  end  is  coiled  to  receive  the  ordinary 
electrode  cord  pm,  the  other  is  left  plain.  The  tube  is  almost  filled 
with  plain  water  and  the  wires  extend  through  the  corks,  with  their 
interior  ends  approximating  each  other  only.  The  closer  the  stronger 
the  current  due  to  lessened  water  resistance.  With  this  electrode  the 
most  delicate  or  strongest  possible  cm'rent  may  be  obtained.  The 
delicate  is  needed  for  touching  fillmgs  or  dentm.  In  use  one  electrode 
is  held  in  the  patient's  hand,  the  other  by  the  operator.  The  electric 
cm-rent  is  of  no  definite  use  with  gold  crowns  imless  an  opening 
large  enough  to  obviate  conduction  by  the  gold  to  the  gum  be  made. 
Here  the  thermal  test  may  cause  response  or  on  drilling  sensation  be 
secured.  A  mild  cm-rent  should  always  be  used  miless  there  is  no 
response,  when  the  strength  of  the  current  should  be  increased.  It 
is  generally  possible  to  test  some  evidently  vital  tooth  nearby  as  a 
control.  If  the  fihmg  reach  the  gum,  the  cm-rent  may  be  transmitted 
by  it.  The  possibility  of  contact  of  the  filling  with  another  in  a  \'ital 
tooth  is  to  be  remembered.  Insulation  with  rubber  dam  is  indicated 
even  if  only  rmi  between  teeth. 

There  are  various  grades  of  response  even  in  similar  fiUings  in  the 
same  mouth,  equally  worn  dentin,  cavities,  etc.  The  writer  doubts  if 
any  definite  judgment  may  be  obtained  of  the  pathological  conditions 
of  a  pulp  that  can  be  depended  upon  and  not  better  indicated  by  other 
tests,  though  of  course  the  more  irritated  the  pulp  the  greater  the 
response.  Very  feeble  response  may  warrant  entrance,  but  tests 
should  be  renewed  as  one  proceeds  and  symptoms  and  other  tests 
should  confirm  the  diagnosis.  Sharp  response  indicates  vitality. 
When  the  filling  goes  to  the  gimi  and  response  is  obtained,  it  is  well  to 
touch  the  gum  alone  to  determine  if  the  shock  is  the  same. 

In  a  few  cases  with  vital  pulps  no  response  has  been  obtained  upon 
repeated  tests  and  the  vital  pulp  has  been  drilled  mto.  Usually 
secondary  dentin  is  the  msulator  probably  not  containing  vital 
fibers  when  the  test  is  negative..  The  test  is  valuable  though  assertion 
to  the  contrary  has  been  made,  but  the  writer  believes  no  more  than 
determination  of  vitality'  should  be  demanded  of  it. 


MOIST  GANGRENE  OF   THE  PULP 


487 


In  doubtful  cases,  such  as  that  shown  in  Fig.  478,  radiograph  is 
vahiable,  and  indicates  at  least  the  removal  of  the  filling  for  further 
diagnosis  and  treatment.  A  root  filling  or  a  granuloma  are  evidence 
of  pulp  death.  It  does  not  distinguish  a  dead  pulp  if  dentin  is  still 
over  the  horn. 

The  presence  of  a  fistula  near  a  discolored  tooth  is  strong  evi- 
dence of  pulp  death  with  apical  abscess,  but  pericemental  abscess  on 
a  vital  tooth  must  be  excluded  by  tests  for  vitality,  etc.,  usually  the 
devital  condition  of  the  tooth  is  evident  by  its  color.  If  more  than 
one  tooth  ofters  confusion  one  should  explore  the  direction  of  the 
fistula  or  employ  a  radiograph. 


Fig.  478 


Fig.  479 


Moist  gangreDe.  Radiograph  of 
unfilled  root  canals  with  large  mass 
of  filling  material  built  in  over 
them.     (Price.  1) 


Case  showing  apparent  apical  infec- 
tion.    Pulp  positively  \'ital. 


Movement  at  the  root  apex  on  tapping  a  tooth,  while  a  finger  is 
placed  o\er  the  apical  region,  indicates  some  bone  disappearance  there 
(Talbot),  but  the  sign  must  only  be  held  as  corroborative  evidence 
or  as  leading  to  suspicion  of  apical  abscess,  etc. 

In  making  observations  and  tests  one  looks  for  positive  facts  and 
reactions.  If  all  are  negative,  carefuUy  drilling  out  a  fillmg,  retesting, 
endeavoring  to  get  some  test  reaction,  especially  sensitivity  at  one 
side,  and  response  to  thermal  or  electric  test.  With  still  no  reaction 
one  may  advance  continuously  toward  the  pulp  and  even  before 
exposure  may  obtain  the  signs  desired.  In  a  very  few  cases,  all  signs 
are  negative  and  one  must  either  drill  to  the  pulp  or  let  the  pulp 
alone. 


MOIST  GANGRENE  OF  THE  PULP  (PULP  PUTREFACTION). 

Definition. — By  moist  gangrene  of  the  pulp  is  meant  death  of  pulp 
tissue  en  masse  in  a  moist  state  (see  page  481)  and  by  pulp  putrefac- 
tion its  subsequent  decomposition  by  the  action  of  putrefactive  agencies. 

1  Items  of  Interest,  1901. 


GANGRENE  OF  THE  PULP 

That  moist  gangrene  may  occur  before  putrefaction  was  shown  on 
page  481.  They  are  usually  classed  together.  As  putrefactive  decom- 
position is  the  essential  feature  in  these  cases,  and  that  which  gives 
the  process  its  pathological  significance,  the  causes,  nature,  effects, 
and  treatment  of  putrefactive  decomposition  of  the  pulp  are  included 
under  this  subheading. 

It  may  be  partial,  as  when  the  bulb  of  a  pulp  only  is  dead  or  when 
the  bulb  and  one  canal  filament  is  devitalized.    It  may  be  total. 

Causes. — ^The  causes  of  moist  gangrene  are  such  as  may  cause  the 
death  of  the  pulp  and  its  subsequent  decomposition  by  bacteria. 
Without  bacteria  putrefaction  cannot  occur.  Among  these  the  Strep- 
toccus  brevis  (viridans)  is  prominent,  but  the  Bacillus  putrificus 
and  Streptococcus  viridans,  especially  the  latter,  have  latterly  been 
strongly  urged  as  the  cause.  Sieberth,^  using  teeth  with  dead  pulps 
not  too  closely  exposed,  found  streptococci  as  the  common  organism, 
only  occasionally  contaminated  by  others.  Goadby,  Kantarowicz  and 
Niedergesass  found  Streptococcus  brevis  (viridans)  in  deep  layers  of 
decalcified  dentin,  and  as  the  Streptococcus  brevis  are  the  chief  ones 
found  in  apical  chronic  abscess,  Hartzell  and  Henrici  argue  that  it  is 
probably  the  sole  organism  causing  non-purulent  pulp  death.  Four 
types  of  cases  are  seen:  (1)  In  teeth  apparently  sound;  (2)  in  teeth 
filled,  but  the  canals  not  treated — i.  e.,  death  of  the  pulp  has  occurred 
after  filling;  (3)  in  teeth  filled  with  canals  partly  filled;  (4)  in  teeth 
having  open  cavities  and  canals. 

In  the  first  type  of  cases  the  bacteria  may  enter  by  way  of  the 
blood  channels,  but  it  is  not  improbable  that  slight  cracks  or  histo- 
logical defects  in  the  enamel  may  admit  to  the  dentinal  tubules  the 
necessary  bacteria,  or  that  they  may  gain  entrance  by  way  of  the 
cementum  and  dentin  at  the  neck  of  the  tooth,  (See  Caush's  Tubes). 
The  inference  is  similar  in  case  of  trimmed  crowns  of  teeth  underlying 
gold  caps.  The  infection  might  occur  by  way  of  the  gingival  groove 
and  pericementum,  hematogenously  which  might  per  se,  cause  pulp 
inflammation  and  death  or  infect  a  pulp  dead  by  other  causes  (see 
pyorrhoea) . 

Many  of  these  teeth  do  not  develop  acute  abscesses  even  after  the 
tooth  has  become  dark  in  color;  granuloma  may  perhaps  be  present. 
If  the  dentin  be  exposed,  as  at  the  incisal  edge,  the  abscess  may 
develop.  The  entrance  of  air  or  beginning  of  treatment  often  starts 
an  abscess  unless  antisepsis  is  instituted. 

The  access  of  oxygen  increases  the  virulence  of  the  bacteria  present, 
though  in  some  cases  others  may  be  introduced. 

1  See  Hartzell  and  Henrici:  Jour.  Nat.  Dent.  Assn.,  May,  1917. 


MOIST  GANGRENE  OF  THE  PULP 


489 


Pigment. 


Fig.  480 
Sulphur  +  hemoglobin. 


In  the  filled  cases  crevices  about  the  c^o^vll  and  root  fillings  may 
admit  bacteria,  which  may  pass  through  the  spaces  in  even  secondary 
dentin  in  some  amount.  On  the  other  hand,  it  is  irrational  not  to 
admit  the  possibility  of  an  infection  via  the  circulation  (for  example 
from  another  focus  of  infection). 

In  cases  of  obvious  pulp  infection  beneath  fillings — e.  g.,  suppura- 
tion of  the  pulp — the  bacteria  necessary  are  in  situ. 

In  the  open  cases  the  infection 
obviously  arises  from  the  mouth 
and  a  varied  infection  may  result. 

Pathology  and  Morbid  Anatomy. 
— The  pulp  being  wholly  or  partly 
dead  from  any  cause  whatever, 
saprophytic  bacteria  gain  access 
to  it,  if  not  already  present,  and 
the  serial  decomposition  it  under- 
goes is  in  exact  correspondence 
with  that  of  moist  gangrene  or 
putrefaction  in  other  localities. 
In  this  serial  decomposition  albu- 
minous substances  are  first  trans- 
formed into  peptones  and  allied 
substances,  some  of  them  being 
very  toxic.  Compound  ammon- 
ias, known  as  ptomains,  or  animal 
alkaloids,  such  as  putrescin, 
neuridin,  and  cadaverin,  are 
probably  next  formed.  Next  the 
nitrogenous  bases — leucin,  tyrosin 
(amido-acid),  and  the  amines 
(methyl,  ethyl,  and  propyl) — 
make  their  appearance,  together 
with  organic  fatty  acids,  Next 
aromatic  products,  indol,  phenol, 

cresol,  etc.,  and  finally  hydrogen  sulphid,  ammonia  sulphid,  carbon 
dioxid,  and  water.  By  alternating  processes  of  hydration,  reduc- 
tion, and  oxidation,  bodies  of  increasing  simplicity  of  chemical 
composition  are  formed.  "Fermentation  and  putrefaction  can  only 
occur  where  the  fungi  concerned  live."  The  contents  of  the  tubules 
(fibrillse)  also  are  putrefied.  These  products  are  derived  from  the 
following  chemical  constituents  found  in  normal  pulps,  according 
to  Hodgen:  Proteins  and  albuminoid,  fibrin,  hemoglobin,  collagen, 
elastin,  fats,  tripalmitin,  stearin,  and  olein. 


CO2,  NH3; 

H2O  and  H3S. 


Aromatic  and 
fatty  prod- 
ucts. 

Ptomains. 


Peptones. 


Diagram  illustrating  the  more  com- 
plete decomposition  of  the  pulp  at  its 
coronal  end. 


490  GANGRENE  OF  THE  PULP 

The  irritant  bodies  are  probably  the  gases  and  ptomains  which 
have  experimentally  been  found  capable  of  producing  suppuration  in 
the  absence  of  bacteria.    The  bacteria  are  also  irritant. 

The  hydrogen  sulphid  combines  with  the  HX3  of  proteid  origin, 
to  form  ammonium  sulphid  (NH4)2S,  which,  again,  combines  with 
the  iron  in  the  hemoglobin  of  the  red  corpuscles,  producing  ferrous 
sulphid,  Fe2S,  which  darkens  the  decomposing  tissue,  and,  entering 
the  tubules,  stains  the  dentin  a  slate-gray  or  bluish-black  color. 
Other  derivatives  of  hemoglobin  may  be  responsible  for  the  yellowish 
brown  discoloration  often  seen  in  cases  in  which  bacteria  have  not 
reached  the  pulp  until  long  after  pulp  death.  The  color  is,  therefore, 
not  due  to  the  presence  of  hydrogen  sulphid. 

Miller^  found  that  the  reaction  in  cases  of  putrefaction  was  alkaluie 
unless  a  certain  percentage  of  sugar  was  introduced  into  the  medium, 
when  it  was  acid.  He  explains  the  voluminous  foul  odor  of  confined 
dead  pulps  as  due  to  the  absence  of  oxygen  of  air.  If  present  as  in 
open  pulp  cavities  the  gases  escape,  the  volume  being  therefore 
reduced,  oxidation  of  gases  increased,  and  an  acid  reaction  due  to 
entering  carbohydrate  permitted.  The  exact  nature  of  pulp  decom- 
position is  in  some  doubt. 

Fig.  480  is  a  diagram  illustrating  these  changes;  it  being  assumed 
that  the  decomposition  is  most  advanced  at  the  crown  portion  of  the 
pulp,  owing  to  the  entrance  of  bacteria  at  that  point. 

In  the  early  stage  of  the  process  the  gangrenous  pulp  resembles 
a  yellowish  mass  of  sloughing  tissue,  with  reasonably  tough  con- 
sistence, which  can  be  easily  remoA'ed.  In  the  later  stages  it  is  more 
decomposed  and  dark  and  jelly-like,  and  yields  to  the  broach. 
Naturally  the  greatest  number  of  fungi  will  have,  by  multiplication, 
invaded  and  putrefied  that  end  nearest  the  source  of  infection,  while 
the  more  consistent  (less  putrefied)  portion  of  the  pulp  will  exist 
at  the  apex.  In  the  final  stages  nothing  but  fluid,  or  even  an  almost 
dry  canal,  may  be  found.  This  last  condition  must  not  be  con- 
founded with  dry  gangrene.  If  fluid,  or  odor  without  fluid  (gases), 
be  present  the  case  is  one  of  moist  gangrene. 

Gangrenous  pulps  d(i  not  necessarily  produce  abscesses  at  once, 
but  often  clinical  history  shows  that  a  year  or  two,  or  even  more, 
may  elapse;  the  possibility  of  granuloma  as  an  intermediate  step 
being  admitted;  though  as  short  a  time  as  two  or  three  weeks  has 
sometimes  been  sufficient.  In  one  case  of  a  boy,  aged  ten  years,  the 
time  between  a  capping  of  a  bleeding  pulp  with  Jodoformagen  and 
the  presence  of  a  fistula  upon  the  gimi  was  but  two  weeks.    It  was, 

1  MicroSrganism  of  the  Human  jSIouth,  1890. 


MOIST  GANGRENE  OF  THE  PULP  491 

however,  in  a  temporan'  first  molar,  and  the  cement  covering  the 
cap  was  found  to  be  loose. 

The  forcing  of  gangrenous  pulp  tissue  by  instrumentation  into 
apical  tissue  generally  results  in  an  abscess,  even  when  extraneous 
bacteria  are  presumably  not  introduced. 

The  irritating  substances  in  a  decomposing  pulp  are  presumably 
the  bacteria,  the  ptomains,  and  the  expanding  gases. 

Many  decomposed  pulps  produce  no  pain,  but  in  these  cases 
the  gases  may  escape  via  dentinal  tubules  and  leaks  about  fillings 
(Fig.  478)  or  the  condition  of  granuloma  is  established,  owing  to  the 
Streptococcus  viridans  type  of  infection. 

Clinically,  putrefactive  pulps  may  be  found  in  sound  teeth,  in 
filled  teeth,  and  in  teeth  the  pulp  ca\'ities  of  which  are  open  to  the 
oral  fluids,  either  actually  or  through  the  medimn  of  open  tubules 
in  the  dentin  over  them,  or  in  apical  portions  of  poorly  cleansed  or 
partly  filled  canals.  A  cotton  dressing  having  a  bad  odor,  or  an 
apparently  empty  apical  portion  of  canal  or  .a  leaky  gutta-percha 
canal  filling  associated  with  a  bad  odor,  even  though  the  pulp  has 
been  successfully  removed,  have  a  similar  pathology.  There  is 
little  difference  in  principle  between  putrefactive  serum  or  tubule 
contents  and  a  putrefactive  pulp.  Any  of  these  may  cause  abscess 
or  remam  quiescent.  There  may  be  apical  granuloma,  but  in  many 
cases  there  is  no  evidence  in  the  radiograph. 

Symptoms. — The  sjTnptoms  are  opacity  of  the  tooth  evident  to 
the  eye  or  noted  by  transmitted  light,  bluish  or  broTVTiish  discolora- 
tion of  varying  degrees,  odor,  and  discoloration  of  the  dentin  in  a 
cavity. 

There  is  a  lack  of  response  to  tests  for  vitality  fsee  page  483). 
Sometimes  a  bad  taste  due  to  leakage  about  fillings  is  present.  Upon 
drilling  out  a  filling  the  odor  of  putrefaction  may  be  clearly  noticed 
even  before  entrance  of  the  canal,  and  sometimes  rises  to  the  operator's 
nostrils.  The  odor  of  the  bur  cuttings  is  diagnostic  in  less  pronounced 
cases.  The  gases  may  be  present  in  quantity  without  sjTnptoms  of 
pain.  Looseness,  tenderness  to  percussion,  incipient  and  acute 
abscess,  or  a  chronic  fistula  are  evidences  of  pericemental  irritation. 
Granuloma  or  partial  root  filling  noted  by  radiography  is  corrobora- 
tive evidence  (see  page  487). 

Pain  to  heat,  whUe  usually  indicative  of  pulp  irritation,  also  some- 
times occurs,  and  is  explainable  upon  the  same  theory  of  the  expan- 
sion of  gases  against  vital  tissue — in  this  case  the  apical  tissue — 
though  sometimes  a  pulp  remnant  is  present.  These  symptoms 
are  aU  explained  by  the  pathology  of  the  condition. 

A  confusing  condition  clinically  is  found  where  one-half  of  a  pulp 


492  GANGRENE  OF  THE  PULP 

has  died  and  undergone  decomposition,  as  in  molars,  the  other  half 
remaining  vital,  although  the  seat  of  infection  and  inflammatory 
action.  So  far  may  this  condition  go,  that  abscess,  acute  or  chronic, 
may  be  present  upon  the  root  of  one  tooth  long  before  the  second 
segment  of  the  pulp  has  succumbed.  The  diagnosis  is  usually  one 
of  pulp  putrefaction,  perhaps  rendered  doubtful,  by  a  response  to  the 
thermal  changes  or  electrical  tests,  which  doubt  can  only  be  cleared 
up  by  finding  the  dead  and  ulcerated  portions. 

In  one  case  of  a  lower  molar  with  a  fistula  related  with  the  distal 
root  I  found  the  pulp  apparently  vital  upon  entering  the  pulp  chamber 
with  a  bur  at  a  point  about  midway  between  the  horns.  There  was 
apparently  a  persistence  or  hypertrophy  of  the  pulp  bulb  attached  to 
the  mesial  filaments.  The  distal  canal  was  found  to  contain  only  the 
fluid  remains  of  a  dead  pulp  filament.  In  cases  seen  at  the  right 
time  the  bulbal  half  of  a  pulp  may  be  gangrenous  with  or  without 
positive  putrefaction,  while  the  apical  half  is  still  vital. 

J.  H.  McQuillen^  recorded  a  case  of  longitudinal  fracture  of  a 
bicuspid  tooth  extending  from  the  sulcus  to  the  bifurcation  of  the 
roots,  and  which  was  apparently  due  to  the  expansion  of  the  gases 
of  decomposition.  Poinsot^  records  a  similar  case,  and  states  that 
several  teeth  containing  decomposed  pulps  confined  in  a  glass  tube 
caused  the  latter  to  break. 

Fig.  481 


Tooth  split  by  gas.     (Roff.) 

Dr.  S.  H.  Roff,^  of  Cincinnati,  Ohio,  has  presented  the  case  shown 
in  Fig.  481.  He  had  it  under  observation  for  seven  years.  He 
regarded  the  case  as  one  of  slow  progressive  cracking  (a  run)  with 
final  irritation  and  death  of  the  pulp  and  the  final  clean  longitudinal 
fracture  as  due  to  the  gases  from  the  partially  decomposed  pulp. 
When  one  considers  the  fact  that  wet  plugs  of  soft  wood  will  split 
granite  boulders  we  must  accept  the  possibility  of  tooth  fracture 
by  gas  pressure. 

»  Dental  Cosmos,  1871.  2  jbid.,  1901. 

3  Items  of  Interest,  March,  1912. 


MOIST  GANGRENE  OF  THE  PULP  493 

Observations  previous  to  that  of  McQuillen  have  recorded  a  sound, 
as  of  an  explosion,  to  have  occurred  simultaneously  with  the  fracture 
of  the  tooth.  I  have  looked  all  my  professional  life  for  such  a  case, 
but  though  I  have  seen  quite  a  number  of  clean  fractures  I  have 
never  been  able  to  eliminate  the  possibility  of  fracture  from  ordinary 
causes  and  in  some  of  the  cases  have  had  positive  histories  of  direct 
violence.  Peculiar  fractures  of  roots  are  shown  under  the  caption  of 
Mechanical  Injury.  The  cases  in  Figs.  246  and  249  may  have  been 
due  to  gas  as  there  was  no  history  of  violence  and  the  crowns  were 
intact  except  for  a  large  filling  in  one  case  and  a  crown  in  the  other. 

The  direct  result  of  partial  pulp  putrefaction,  whether  as  a  result 
of  gangrene  or  suppuration,  is  inflammation  of  the  remainder  of  the 
pulp;  w^hen  there  is  no  remainder,  inflammation  of  the  apical  tissue. 
The  first  result  of  apical  ii-ritation  may  be  either  acute  abscess  or  far 
more  commonly,  a  chronic  proliferative  inflammation  known  as 
granuloma,  which  frequently  having  no  s\TQptoms,  should  be  sus- 
pected in  every  case  and  its  presence  or  absence  determined  by 
radiography.    This  condition  is  to  be  later  considered. 

Treatment. — The  pulp  being  presumably  infected,  all  quiescent 
gangrenous  pulps  or  putrefactive  conditions  under  any  conditions 
discovered  indicate  a  similar  treatment,  namely,  first  disinfection  to 
remove  or  kill  bacteria  which  might  cause  an  abscess  and  at  the 
same  time  to  destroy  the  chemical  nature  of  the  gases  and  ptomains. 
After  this  the  canals  are  to  be  thoroughly  opened,  cleansed,  further 
disinfected  for  the  sake  of  surety,  and  later  filled;  granting  granu- 
loma or  chronic  apical  abscess  to  be  possibly  present  the  added 
responsibility  is  merely  to  prevent  introducing  into  an  abnormal  tissue 
bacteria  which  may  cause  an  acute  abscess  and  to  destroy  such  bac- 
teria as  may  be  there  present  without  such  injury  to  the  soft  tissue  as 
may  prevent  regeneration  of  sterile  tissue. 

The  profession  is  largely  in  doubt  regarding  the  actual  value  of  the 
medicaments  used  in  canals  as  sterilizing  agents.  Brooks  and  Price,^ 
following  the  general  method  laid  down  by  Dahlgren,^  practically 
eliminated  all  remedies  as  agents  capable  of  disinfecting  canals  with 
100  per  cent,  efliciency,  with  the  exception  of  dichloramin-T  in  15 
per  cent,  solution  in  eucalj'ptol,  and  chlorazen,  in  4  per  cent,  aqueous 
solution,  in  six  daily  treatments,  both  considered  too  painful  and 
destructive  for  use,  and  Howe's  ammoniated  sih'er  nitrate  and  forma- 
lin, which  seemed  to  sterilize  in  about  ten  minutes,  but  was  objec- 
tionable on  account  of  the  discoloration. 

1  Journal  of  Nat.  Dent.  Assn.,  March,  1918. 

2  Ibid.,  1917. 


494  GANGRENE  OF  THE  PULP      • 

Howe^  introduced  the  above  method  of  disinfection  of  root  canals 
and  tubuli  and  inaccessible  root  ends,  which  has  received  the  en- 
dorsement of  Price  and  Brooks^  working  in  the  Research  Laboratory 
of  the  N.  D.  A.    (Described  on  page  477.) 

Howe  uses  occasionally  a  loibber  pellet  to  force  the  solution  into 
the  canal  and  abscess  tract  if  such  exist. 

For  final  treatment  the  canals  are  filled  with  a  paste  of  zinc  oxid 
and  eugenol  plus  aristol,  into  which  is  thrust  a  gutta-percha  point. 

Howe  claims  immediate  sterilization  even  in  cases  of  aborted  acute 
abscesses,  not  only  of  the  canal,  but  of  abscess  tracts  (and  fistulse), 
with  allayed  irritation  rather  than  irritation  from  the  treatment. 

The  method  offers  much  hope  for  unexplorable  root  ends  in  cases 
of  both  recently  removed  pulps  and  septic  cases.  Howe  claims  canal 
sterility  in  all  cases.  Price  and  Brooks  state,  in  confirmation,  that 
sterilization  seems  likely  in  about  ten  minutes.  The  dam  is  preferably 
applied  or  the  tissues  otherwise  protected.  The  hands  should  be 
protected  with  rubber  gloves  or  finger  cots. 

Prinz^  claims  that  dichloramin-T  in  5  per  cent,  solution  in  chlor- 
cosane  (a  heav}^  oil  made  from  hard  paraffin  by  replacing  part  of  its 
hydrogen  by  chlorin)  is  tolerated  by  tissues  and  will  sterilize  a  root 
canal  (by  test  of  the  incubated  scrapings  with  sterile  cleansers)  after 
about  three  applications. 

Unfortunately,  he  states  that  in  removing  the  canal  contents  while 
using  this  medicament,  if  extreme  care  be  not  used  to  avoid  forcing 
canal  contents  bej^ond  the  apex,  an  acute  abscess  will  ensue.  If  the 
opening  does  not  reach  to  the  apical  tissue  at  the  first  sitting,  a  dress- 
ing should  be  sealed  in,  but  should  not  be  sealed  in  if  no  attempt  is 
made  to  remove  the  canal  contents. 

This  of  necessity  limits  its  use  as  a  canal  germicide  to  large  open 
canals  or  those  which  can  be  reasonably  opened  under  dichloramin-T 
or  by  other  means,  as  a  fiuther  means  of  sterilizing  apical  tissues. 

Dimham^  states  that  when  well  mixed  with  septic  material  dichlora- 
min-T, 2  per  cent,  solution,  disinfects  in  less  than  half  a  minute 

The  dressings  are  to  be  applied  on  sterile  paper  canal  points,  the 
endeavor  being  to  coat  the  canal  and,  if  possible,  apply  it  to  the  apical 
tissue.  The  technic  of  canal  cleansing  is  with  sterile  broaches  dipped 
into  the  dichloramin-T  (in  a  separate  medicament  glass)  and  slowly 
worked  into  the  canal,  wiping  the  broaches  on  sterUe  cheesecloth  or 
bibulous  paper.  For  canals  requiring  enlargement,  Prinz  recom- 
mends preliminary  opening  with  sulphuric  acid  and  neutralizing  this 

'  Dental  Cosmos,  September,  1917.  -  Jour.  Nat.  Dent.  Assn.,  March,  1918. 

'  Dental  Cosmos,  December,  1918,  p.  1078. 

*  See  Prinz,  Dental  Cosmos,  December,  1918,  p.  1077, 


MOIST  GANGRENE  OF  THE   PULP  495 

with  sodium  dioxid,  washing  out,  reasonably  drying,  leaving  the 
natiual  moisture  to  assist  in  evolution  of  chlorin  and  dressing  with 
dichloramin-T.  He  cites  successful  cases  so  treated,  though  from 
past  experience  with  preliminary  sulphuric  acid  opening  as  a  primary' 
step  I  would  feel  a  need  of  caution  in  the  procedure;  however,  if  the 
facts  are  generally  as  stated,  there  can  be  no  contention  over  the 
method. 

Buckley  claims  that  one  or  two  applications  of  formocresol  (cresol 
and  37  per  cent,  aqueous  formaldehyde  solution  equal  parts)  in  the 
pulp  cavity  only  will  so  sterilize  or  inhibit  bacteria  that  the  canal 
can  be  safely  opened  mechanically  if  asepsis  be  observed. 

Brooks  and  Price  rate  formocresol  as  a  germicide  at  93  per  cent, 
efficiency  in  twenty-four-hour  treatment  with  croTMi  sealed  and  root 
apex  open,^  but  there  have  been  niunerous  mstances  in  the  writer's 
practice  in  which  pus  flows  from  apical  tissue  have  been  checked  by  its 
use.  Likewise,  after  its  use  there  is  seldom  any  ill  result  in  rather  diffi- 
cult canal  openmgs.  Buckley,  in  his  book,- illustrates  good  results  follow- 
ing its  use  quite  comparable  to  any  I  have  seen  illustrated.  Although 
it  has  been  claimed  that  formaldehyde  produces  the  result  of  inducing 
a  granuloma  in  time  when  applied  to  healthy  tissue  and  Grove^  has 
produced  experimental  evidence  to  show  irritation  of  normal  tissue, 
it  does  not  follow  that  diseased  tissue  will  be  unfavorably  affected 
nor  even  that  somewhat  irritated  normal  tissue  maj"  eventual!}"  be 
damaged  provided  asepsis  be  produced.  Grove  has  experimentally 
sho^Mi  that  formocresol  mereh'  sealed  in  the  pulp  chamber  will  find 
its  way  to  the  apical  tissue.  He  claims  hardening  of  such  tissue, 
To  me  this  seems  to  rather  set  an  advantage  for  formaldehyde  gas. 
Our  object  is  to  so  affect  diseased  tissue  as  to  render  it  sterile,  leaving 
to  Natiu-e  the  work  of  removing  even  dead  aseptic  tissue  if  necessary 
through  aseptic  absorption.  In  this  connection  the  action  of  phago- 
cjiies  should  be  depended  upon  as  a  means  to  an  end. 

From  clmical  evidence  I  am  not  satisfied  that  forniocresol  and  its 
congeners  is  so  irritant  as  supposed.  I  frequently  find  apical  tissue 
showing  sensitivity  after  several  applications  and  in  cases  of  ulcerated 
pulp  filament  have  often  found  them  vital  after  even  pure  formocresol 
has  been  sealed  in  the  pulp  chamber.  The  case  shown  in  Figs.  482 
and  483  is  offered  as  evidence  as  are  Figs.  459  and  460.  Following 
Price  and  Brooks  it  would  seem  that  to  attain  the  best  results  one 
should  change  the  dressing  every  twenty-fom"  hours  until  sterile. 

1  Deduced  by  the  editors  from  their  experiments  in  Jour.  Nat.  Dent.  Assn.,  March, 
1918. 

2  Dental  Materia  Medica,  Pharmacology  and  Therapeutics,  4th  ed. 

3  Dental  Cosmos,  Februarj-,  1913. 


496 


GANGRENE  OF  THE  PULP 


The  only  other  valuable  means  of  sterilization  is  the  introduction 
of  medicaments  by  means  of  the  galvanic  cm-rent  called  cataphoresis 
if  the  positive  pole  at  the  canal  drives  the  electropositive  medica- 
ment unchanged  toward  the  negative  pole  in  the  hand  causing  it  to 
penetrate  apical  tissue  or  anaphoresis  if  the  negative  pole  at  the  canal 
drives  an  electronegative  medicament  unchanged  toward  the  positive 
pole  in  the  hand  or  electrolytic  medication  if  the  medicament  is 
decomposed  into  its  elements  some  of  the  ions  being  electronegative 
appearing  at  the  positive  pole  (anions)  and  the  others  being  electro- 
positive appearing  at  the  negative  pole  (cations).  Of  these  the  elec- 
trolytic medication  is  the  more  valuable,  the  ions  being  nascent, 
owing  to  the  electrolytic  dissociation  and  therefore  more  active.  The 
most  valuable  ions  are  those  of  zinc,  copper,  iodin,  and  chlorin. 

Fig.  482 


Fig.  483 

r 

S 

f 

k. 

J 

Lower  molar,  showing  marked 
granuloma  on  distal  root.  Mesial 
root  denuded,  but  having  remarkably 
little  pus  discharge.  Condition  of 
this  root  due  to  a  longitudinal  frac- 
ture discovered  on  extraction. 


Same  case  as  Fig.  482  after  six 
months.  Roots  purposely  deluged 
with  formocresol.  Distal  root  con- 
tains a  gummy  iodoform  paste  (see 
page  476).  Note  marked  improve- 
ment in  granuloma  on  distal  root. 
(Position  unfortunately  reversed.) 


Sturridge^  recommends  a  positive  zinc  electrode  and  a  3  per  cent, 
solution  of  zinc  chlorid  as  an  electrolytic  in  the  canal  to  dissociate 
positive  zinc  ions  which  migrate  into  the  tissues  and  chlorin  which 
remains  at  the  positive  pole,  though  it  may  slowly  diffuse  from  that 
point  as  new  ions  are  formed,  or  a  positive  copper  electrode  and  a 
2  per  cent,  solution  of  copper  sulphate  to  cause  the  migration  of  copper 
ions  or  iodin  in  the  form  of  tincture  (a  solution)  with  a  negative  pole 
at  the  canal. 

Prinz^  recommends  a  positive  iridioplatinum  electrode  at  the  canal 
and  a  1  per  cent,  sodium  chlorid  solution  as  electrolyte  to  pro- 
duce chlorin,  which  being  electronegative  forms  about  the  positive 
electrode.  This  will  not  migrate  into  the  tissues  unless  formed  in 
contact  with  them,  but  in  the  canals  will  produce  surface  sterilization 


1  Dental  Electro-Therapeutics,  p.  252. 

2  Dental  Cosmos,  April,  1917. 


MOIST  GANGRENE  OF  THE  PULP  497 

if  employed  for  as  many  minutes  as  are  equal  to  a  quotient  produced 
by  dividing  the  constant  figure  30  by  the  milliampere  reading  of  the 
milliampere  meter,  for  example,  if  a  current  of  3  ma.  is  passing  ten 
minutes  are  required,  if  2  ma.,  fifteen  minutes. 

The  cataphoric  outfit  being  the  same  as  the  so-called  ionization 
outfit,  page  327  and  the  Chapter  on  Uses  of  Electricity  are 
referred  to. 

It  is  evident  that  the  best  use  of  electrolytic  medication  is  in  cases 
of  ready  access  to  at  least  apical  portions  of  canals  so  that  the  method 
fails  to  reasonably  apply  to  the  early  sterilization  of  fine  canals. 

In  an  endeavor  to  correlate  for  the  purposes  of  treatment  of  pulp 
putrefaction,  I  believe  the  following  methods  to  be  good  practice,  time 
being  a  factor  secondary  to  results  and  avoidance  of  injury : 

1 .  In  teeth  in  which  eventual  discoloration  would  not  much  matter 
and  canals  liable  to  be  difficult,  the  emplo;yTnent  of  Howe's  silver 
nitrate  and  formalin  treatment  for  a  first  sitting.  Thorough  opening 
with  acid,  etc.,  the  same  being  neutralized  and  the  repetition  of  the 
Howe  treatment  at  the  second  sitting.  A  repetition  of  the  Howe 
treatment  and  root  filling  at  the  third  sitting  (see  page  477). 

2.  In  te(3th  liable  to  afford  access  to  root  apices  the  placement  of 
formocresol,  geranium  formol  or  5  per  cent,  aqueous  formaldehyde 
solution  in  the  pulp  cavity  onh'  for  the  first  or  first  two  sittings  to 
avoid  apical  infections.  Thorough  mechanical  cleansing  at  the  second 
or  third  sitting,  this  to  be  followed  by  dichloramin-T,  5  per  cent,  in 
chlorcosane  as  recommended  by  Prinz.  Repetition  at  the  fourth  and 
fifth  sittings  or  the  use  of  Prinz's  technic  throughout  (see  page  494). 

3.  In  apparently  fine  canals  it  may  be  best  to  apply  formocresol, 
etc,,  to  the  pulp  chamber  once  or  twice,  later  open  with  acids,  etc. 
(see  pages  443  and  465),  and  apply  the  Howe  treatment  as  indicated. 

4.  In  case  of  granuloma,  the  Howe  treatment  ma}'  give  results  in 
inoperable  root  apices.  This  is  as  yet  an  unknown  factor.  If  possible 
after  disinfection  in  operable  roots  an  opening  should  be  made  with 
broaches  through  the  root  apex. 

Thereafter  phenolsulphonic  acid  (Buckley)  or  5  per  cent.  dichlora- 
min-T (Prinz)  may  gently  be  introduced  into  the  granulomatous  area 
to  sterilize  and  stimulate  new  growth  or  modified  formocresol,  etc.,  may 
be  sealed  in  the  canals,  or  the  area  may  be  treated  electrolytically  by 
means  of  a  copper  point  and  2  per  cent,  copper  sulphate  introduced 
into  the  apical  tissue  and  used  as  the  positive  electrode  (fmiiishes 
copper  ions),  or  the  canal  may  be  filled  with  zinc  chlorid,  3  per  cent, 
and  a  positive  zinc  electrode  used  to  pass  5  ma.  of  current  for  about 
eight  minutes  (Sturridge)  to  either  stimulate  or  disinfect  the  tissues. 
Or  sodium  chlorid  solution  may  be  the  electrolyte,  a  positive  plati- 
32 


498  GANGRENE  OF  THE  PULP 

num  point  in  the  canal  to  liberate  chlorin  and  sodium  ions  (Prinz) . 
Sturridge^  has  pointed  out  that  this  is  a  reversal  of  the  proper  poles. 

"When  formaldehyde  is  relied  upon  the  first  treatment  consists  in 
opening  the  pulp  cavity  and  gently  removing  only  the  bulk  of  decom- 
posed pulp  from  the  pulp  chamber  and  canals,  care  being  employed  to 
avoid  forcing  any  putrid  material  into  the  apical  tissue  by  broaching  or 
plunging  of  the  bur.  Also,  no  bacteria  should  be  introduced  from  out- 
side. This  involves  the  use  of  rubber  dam  and  asepsis,  all  of  which  are 
discussed  on  page  448.  Too  much  advance  should  not  be  made,  the 
first  object  being  sterilization.  The  opening  should  not  be  too  freely 
made,  and  should  be  funnelled  or  countersunk  outwardly  to  secure 
the  seal  against  being  plunged  into  the  pulp  cavity  in  mastication 
(Fig.  484). 

This  being  done,  the  canals  are  dried  with  cotton  and  hot  air,  and 
a  small  pellet  of  cotton  saturated  with  formocresol  or  10  per  cent, 
aqueous  formaldehyde  solution,  or  geranium  formoP  is  to  be  placed 
in  the  pulp  chamber.     - 

I^ — Formaldehyd 40  parts 

Essence  of  geranium,  distilled 20  parts 

Alcohol  80  per  cent 40  parts 

Any  that  has  come  in  contact  with  the  orifice  should  be  removed 
with  alcohol.  The  orifice  is  then  dried  and  a  small  piece  of  dry  spunk 
placed  over  the  application,  but  not  so  as  to  interfere  with  the 
seal.  Quick-setting,  adhesive,  hydraulic  cement  is  now  flowed  into 
the  orifice,  air  bubbles  being  avoided  by  flowing  it  in  with  an  instru- 
ment (Fig.  484) .  A  bit  of  paraf orm  accomplishes  the  same  purpose 
as  the  solution,  namely,  the  liberation  of  formaldehyd  gas. 

When  opportunity  for  self-relief  seems  proper,  as  w^hen  the  operator 
is  leaving  his  practice  for  a  short  time,  or  may  otherwise  be  inacces- 
sible, hot  temporary  stopping  may  be  used  and  the  patient  instructed 
as  to  the  proper  procedure  to  obtain  relief.  An  ordinary  pin  crooked 
at  the  point  by  striking  it  across  any  hard  surface  will  serve  to  pick 
out  the  stopping  and  cotton.  In  all  cases  tight  coverings  must  be 
made,  as  the  object  is  to  concentrate  the  action  of  the  formaldehyd 
gas  upon  the  canal  and  tubular  contents. 

In  some  cavities  it  is  well  to  make  the  covering  first,  as  done  for 
arsenic  (see  Fig.  391),  and  to  seal  the  dressing  in  with  a  further 
addition  of  cement  or  temporary  stopping.  The  latter  does  not 
permit  mastication  like  the  former. 

If  there  be  a  broad  cavity  extending  beneath  the  gum,  it  is  well 
to  press  the  gum  away  with  cotton  pellets,  then  to  form  the  cavity 

1  Dental  Cosmos,  1919. 

2  Geranium-formol  introduced  by  Andr6  and  de  Marion,  I'Odontologie;  abstract 
by  International  Dental  Journal,  1901. 


MOIST  GANGRENE  OF  THE  PULP 


499 


and  open  the  canal  orifices.  Then  a  retention  at  the  cervical  portion 
of  the  cavity  should  be  made,  even  if  it  be  necessary  to  drill  a  series 
of  pits  along  it  with  a  No.  1  bur.  Spunk  is  now  placed  over  the 
pulp  canals  and  quick-setting  amalgam  is  to  be  permanently  built 
in  at  this  part  of  the  cavitj^  When  set  the  spunk  is  withdrawn, 
formocresol  in  cotton  is  placed  instead  of  the  spunk,  and  the  covering 
completed  with  cement.  The  amalgam  is  finished  as  far  as  practi- 
cable at  the  one  sitting,  and  the  case  dismissed.  At  future  sittings 
the  rubber  dam  may  be  applied  and  the  canal  work  done  (Fig.  485). 
When  cavity  walls  are  frail,  spunk  may  be  placed  in  the  pulp  cavity, 
and  a  permanent  cement  lining  built  into  the  cavity.  This  can  be 
perforated  to  the  spunk,  thus  leaving  the  walls  supported  during 
the  treatment.     (See  Figs.  515  and  516.) 


Fig.  484 


Fig.  485 


a,    cotton    and    formocresol;  b,  spunk; 
c,  cement. 


Cervical  wall  built  up  with  amal- 
gam to  permit  canal  sterilization 
and  treatment. 


Formocresol,  introduced  by  Buckley,  consists  of  equal  parts  of  37 
per  cent,  aqueous  formaldehyd  solution  and  cresol,  which  combine 
well. 

According  to  Buckley,  the  formaldehyd  not  only  acts  as  a  germi- 
cide, but  combines  with  the  ammonia  of  ammonium  sulphid  to  form 
urotropin  and  water,  6CH2O  +  4NH3  =  (CH2)6N4  +  6H2O,  and 
with  hydrogen  sulphid  to  form  sulphur  and  methyl  alcohol,  2CH2O  + 
2H2S  =  S2  +  2CH3OH.  The  cresol  is  supposed  to  act  upon  the 
fatty  compounds,  changing  them  into  a  compound  resembling  lysol. 
Thus,  antiseptic  substances  are  formed  from  poisonous  ones.  This 
does  not  necessarily  represent  all  the  reactions  occurring,  as  many 
other  compounds  may  result  from  putrefaction.  The  probability  is 
that  the  thoroughly  bactericidal  action  is  the  one  of  greatest  value. 
This  action  has  been  sho^ATi  by  Mayrhofer  to  be  true  only  for  the 
first  twenty-four  hours;  thereafter  the  bacteria  in  the  tubules  may 
grow  back  into  the  canal  and  the  dressing,  in  spite  of  the  fact  that 
the  odor  of  the  dressing  is  present.  The  canal  should  therefore  be 
mechanically  cleaned  after  twenty-four  hours,  and  a  fresh  application 


500  GANGRENE  OF  THE  PULP 

be  made.^  Mayrhofer  claimed  inability  to  sterilize  permanently 
with  formocresol.  Nevertheless  the  editor  treats  such  cases  at  wide 
intervals  ordinarily  with  impunity.  In  a  few  cases  an  abscess  has 
supervened  after  the  first  dressing,  but  none  as  yet  after  the  second. 
Leakage  of  the  formaldehyd  gas  may  have  been  the  reason,  but  a 
chronic  apical  abscess  has  been  a  suspicion.  Cleansing  and  reaming 
the  canals  at  the  first  sitting  is  another  danger,  even  when  formal- 
dehyd is  subsequently  used.  This  must  sometimes  be  done  as  when 
a  crown  is  broken  away  and  the  root  canal  is  foul. 

Formaldehyd  is  so  efficacious  in  my  hands  that  it  has  until  recently 
displaced  other  methods  in  my  practice  and  I  use  it  despite  the  general 
trend  against  it,  though  occasionally  some  one  publicly  or  privately 
praises  it.  While  this  is  true  for  a  great  majority  of  the  cases,  occa- 
sionally a  patient  is  met  with  whose  tissues  do  not  tolerate  formal- 
dehyd well.  In  such  a  case  if  the  foramen  be  open  as  is  usual  in  such 
cases,  any  of  the  mild  proprietary  antiseptic  washes  as  Listerine, 
Borine  or  Lavoris,  Vernas  lotion  (astringents),  wdth  a  trifle  of  iodo- 
form picked  up  on  the  dressing  seems  to  accomplish  the  work  if 
promptly  renewed.  Weak  ammonia  water  has  been  occasionally  used 
to  counteract  the  formalin. 

When  one  pulp  filament  is  gangrenous  and  another  vital,  the  treat- 
ment is  the  same,  it  being  the  writer's  experience  that  formocresol 
loosely  placed  is  not  incompatible  with  ulcerated  pulps,  and,  indeed, 
is  an  excellent  dressing  for  suppurative  pulps  when  modified  to  a  3 
to  5  per  cent,  strength;  even  full  strength  has  been  acceptably  used. 
Later,  the  vital  portion  is  appropriately  removed. 

When  root  fillings  are  present  in  part  of  a  canal  they  must  be 
remo^■ed  in  order  to  treat  the  balance  of  the  canal. 

The  case  is  thus  resolved  into  one  of  moist  gangrene  and  treated 
accordingly. 

Wax  may  be  removed  by  overheating  with  the  hot  root  drier  and 
absorption  with  cotton,  or  oil  of  cajeput  may  be  used  as  a  solvent. 
Paraffin  may  be  removed  in  like  manner,  xylol  is  a  solvent. 

If  a  cotton  root  filling  be  found  it  sometimes  allows  the  broach  to 
tear  loose.  In  such  case  a  Kerr  broach  is  driven  into  it  to  create 
a  central  opening,  after  which  the  fibers  become  engaged  by  the 
barbed  broach,  though  sometimes  it  must  be  drilled  out. 

Chloroform,  xylol,  oil  of  cajeput  or  eucalyptol  may  be  used  to 
soften  gutta-percha  root  canal  fillings,  and  at  times  the  smallest 
Kerr  or  DoTMiie  broach  is  to  be  bibevelled  at  its  ends  and  used  as  a 
drill,  cutting  its  way.    This  is  very  dangerous  as  perforations  occur 

I  ViuUeumier:  Items  of  Interest,  March,  19X0. 


MOIST  GANGRENE  OF  THE  PULP  501 

if  one  deviate  from  the  gutta-percha.  Gutta-percha  hardens  in  time, 
but  still  cuts  more  readily  with  xylol,  etc.,  than  root  structme.  When- 
ever one  has  to  bore  hard  a  radiograph  with  wire  is  advisable.  Even 
this  may  confuse  as  showing  a  wire  in  good  line  with  the  canal  mesio- 
distally  from  which  one  may  still  diverge  buccolingually.  In  one  case 
even  after  such  a  wire  diagnosis  I  failed  to  find  a  canal  in  a  lateral 
after  two  hours'  search  in  various  directions  (Fig.  514).  Oxychlorid 
and  other  cement  fillings  may  have  50  per  cent,  sulphuric  acid  or 
strong  ammonia  water  applied  to  them  to  assist  in  breaking  up  the 
bond  of  the  cement  by  chemically  destroying  either  the  zinc  oxid  or 
the  acid.  The  drill  will  tamp  the  fluid  into  the  cement  and  cut  the 
cement  at  the  same  time. 

All  root  fillings  of  cement  nature  are  apt  to  be  faulty  when  used 
as  such,  because  the  air  in  the  canal  prevents  ingress.  This  fact  is  of 
importance  in  diagnosis  in  filled  teeth,  giving  evidence  of  chronic 
pericementitis,  i.  e.,  there  is  probably  an  unfilled  portion  of  root 
canal  containing  putrefied  pulp  or  seram.  One  always  seeks  to  drop 
freely  into  a  canal  lumen  beyond  the  root  filling.  In  doing  this  one 
is  liable  to  compress  the  air  or  fluid  in  the  apical  region  of  the  canal 
thus  producing  sensation  and  it  is  advisable  to  stop  and  reapply 
disinfectants  at  least  before  immediately  proceeding  with  the  work. 

Fig.  486 


Little  Giant  pust-puller. 

To  remove  pins  from  roots  a  bibevelled  Kerr  broach  may  be  driven 
into  the  cement  or  dentin  about  it  and  the  drifts  united.  The  pin 
may  often  be  forced  to  one  side  and  then  jigged  loose.  If  there  be 
sufficient  pin  extending  above  the  face  of  the  root  a  "pin  puller" 
such  as  the  "Little  Giant"  (Fig.  486)  may  be  used.  The  S.  S.  White 
Dental  Manufacturing  Company  makes  one  which  extracts  a  pin 
broken  at  or  below  the  level  of  the  root  face  after  trephining  and 
threading  the  pin  (Fig.  487) .  If  the  pin  cannot  be  loosened  it  must  be 
drilled  out  bodily.  A  sharp  round  bur  should  be  used  to  countersink 
the  end  of  the  pin,  and  then  by  the  aid  of  oil  it  is  cut  into  shavings. 
Frequent  desiccation  and  examination  to  observe  the  presence  of  a 
metal  remnant  is  necessary  to  avoid  the  accident  of  perforation.  For 
removal  of  a  plain  bandless  dowel  crowm,  Johnson's  crown  remover 


502 


GANGRENE  OF  THE  PULP 


may  be  tried.  In  case  of  a  banded  dowel  crown  one  must  drill 
through  the  backing,  separate  the  pin  from  the  crown — remove 
the  crown  with  forceps  if  necessary  but  with  care  may  retain  it 


13 


S.  S.  White  post-puller. 
Fig.  488 


Johnson  crown  remover.     (Courtesy  of  Goldsmith  Bros.) 
Fig.  489 


Medicament  glass  for  holding  broaches  in  sterilizing  solution,  etc.     (S.  S.  White.) 


MOIST  GANGRENE  OF  THE  PULP  503 

for  insertion  of  a  new  dowel  the  old  one  being  removed  as  previously 
described.  Sometimes  crowns  must  be  destroyed.  If  chloro-percha 
has  been  used  in  the  setting  (see  page  509)  this  work  may  be  avoided. 
Shell  crowns  may  often  be  perforated  for  a  "tap"  into  the  root  but 
if  poor,  should  be  removed. 

When  for  any  reason  one  must  work  on  a  canal  immediately,  one 
may  either  proceed,  as  in  the  Howe  method,  allowing  ten  minutes  for 
canal  sterilization  or  in  anterior  teeth  use  the  following: 

A  little  dry  sodium  dioxid  is  placed  upon  a  slab  with  a  drop  of 
water  near  it.  A  broach  is  drawn  through  the  water,  then  through 
the  powder,  and  the  adherent  powder  carried  to  the  canal  and  gently 
passed  into  the  moist  putrid  contents  of  the  canal;  a  reaction  occurs 
between  the  water  and  sodium  dioxid  as  follows:  Na202  +  2H2O  = 
H2O2  +  2NaOH,  producing  hydrogen  dioxid  and  sodium  hydrate. 

The  sodium  h^^drate  or  lye  saponifies  all  fatty  matters  and  destroys 
organic  matter,  even  living  matter,  and  the  hydrogen  dioxid  liber- 
ates nascent  oxygen,  which  is  a  disinfectant.  No  oil  or  phenol 
should  be  used  M'ith  dry  sodium  dioxid,  as  an  explosion  may  occur. 
The  use  of  the  alloy  kalium-natrium  in  a  moist  canal  causes  a  dis- 
ruption of  the  water  molecules  with  production  of  flame  by  ignition 
of  part  of  the  hydrogen  and  of  sodium  and  potassium  hydrate  by 
addition  of  (OH)  to  each  metal  making  Na(OH)  and  K(OH). 

The  result  of  the  reaction  should  be  washed  out  with  a  gentle 
stream  of  warm  water,  while  a  broach  is  gently  passed  to  and  fro 
through  the  mass.  The  action  is  then  repeated  as  far  as  it  can  be 
carried. 

The  danger  in  the  use  of  these  materials  lies  in  the  possibility  of 
the  production  of  a  chemical  inflammation  of  the  apical  tissue,  due 
to  the  nascent  hydrates,  if  the  foramen  be  open,  which  inflammation 
may  be  severe.  This  is  only  to  enable  one  to  get  a  canal  ready  for 
sterilization  of  the  tubuli  and  apical  region,  one  must  then  proceed 
to  accomplish  this  as  indicated  on  page  493,  etc. 

The  withdrawal  of  all  cotton  dressings  should  be  done  under  aseptic 
precautions,  and  repeated  as  indicated  on  page  497.  As  this  procedure 
must  be  repeated  to  obtain  sterility  it  should  be  done  as  often  as 
required.  This  based  upon  the  germicidal  value  of  the  medicament. 
To  me  there  seems  little  practical  value  in  a  laboratory  test  of  canal 
sterility.  If  one  wait  on  a  test  the  canal  may  become  infected  mean- 
while. If  it  seems  sterile  there  can  be  no  assurance  of  tubule  or  apical 
sterility  and  in  fine  apices  one  cannot  test  the  most  important  areas. 
The  apical  granuloma  cannot  be  accurately  tested. 

Active  hemorrhage  may  ensue  or  serum  may  ooze  from  the  apical 
tissue.    This  may  be  checked  with  25  per  cent,  pyrozone,  adrenalin 


504  GANGRENE  OF  THE  PULP 

chlorid,  1  to  1000,  or,  preferably,  deliquescent  zinc  chlorid  or  alum  and 
th^TBol,  and  the  medicaments  renewed.  Particularly  such  as  a  mild 
antiseptic  astringent  and  iodoform  (see  page  500) . 

If  the  apical  foramen  be  a  large  one,  and  if  a  pus  flow  follow  the 
removal  of  the  temporary  dressing  and  be  but  slight,  it  should  be 
absorbed  and  medicaments  renewed.  This  is  apical  abscess.  No 
such  thing  as  immediate  root  filling  is  now  admissible  nor  will  be 
until  a  permanently  germicidal  root  canal  filling  shall  be  found. 
Sometimes  a  thick,  glairy  fluid  will  ooze  from  the  apical  tissue.  This 
is  coagulable  lymph,  and  the  parts  require  treatment  in  the  same 
manner. 

In  order  to  prevent  apical  irritation  in  so  far  as  possible,  the  gum 
is  to  be  painted  wdth  ordinary  tincture  of  iodin  or  spotted  with  the 
dental  tincture  of  iodin,  both  lingually  and  buccally,  as  a  counter- 
irritant. 

IJ — Iodin 3iij 

Alcohol §j 

Shake  frequently  for  a  week  or  two.    (Flagg.) 

If  infection  of  the  apical  tissue  by  any  chance  ensue,  either  as  the 
result  of  the  operation  of  canal  cleansing  or  previous  to  operative 
interference,  the  disease  known  as  septic  apical  pericementitis  is 
established. 

Pericementitis  following  the  opening  of  teeth  containing  gangrenous 
pulps  has  been  explained  upon  the  ground  that  the  bacteria  in  the 
absence  of  free  admission  of  oxygen  have  lost  their  virulence,  which 
is  restored  when  the  air  is  admitted.  It  is  quite  likely  that  either 
this  is  true  or 'that  extraneous  bacteria  are  introduced  during  the 
course  of  treatment. 

In  drying  with  the  compressed-air  syringe,  care  should  be  employed 
to  avoid  extensive  emphysema  of  the  cheek,  which  may  be  induced 
by  intense  pressure.  If  it  occur,  the  emphysema  should  be  reduced 
by  manipulation,  with  a  view  to  gently  forcing  the  air  back  through 
the  root.  Christensen^  and  L.  Greenbaum  have  each  reported  a 
case,  and  the  editor  had  his  first  case  when  desiccating  an  accidental 
lateral  perforation.  This  occurred  even  without  close  application 
of  the  syringe  nozzle,  35  pounds  pressure  being  used. 

Another  case  occurred  while  an  upper  lateral  with  large  apical 
foramen  and  even  with  an  open  fistula  was  being  dried  out.  The 
entire  right  cheek  and  lower  eyelid  was  instantly  puffed  up.  The 
patient  called  attention  to  a  stiffness  and  coldness.  It  subsided 
upon  manipulation.    There  might  be  dangerous  sequelae  if  sepsis  were 

'  Dental  Cosmos,  1904,  p.  151. 


MOIST  GANGRENE  OF  THE  PULP  505 

present.  This  applies  more  particularly  to  cases  with  large  foramina 
or  perforations  as  above  noted,  but  care  should  be  employed.  A  hot 
point  electric  drier  used  repeatedly  or  an  Evans's  root  drier  (Fig.  393) 
are  more  valuable  for  the  apical  ends  of  roots,  as  the  air  seldom 
reaches  that  point.  ]\Ioreover,  air  should  be  filtered  before  passing 
through  the  compressor.  Cotton  twists  and  paper  points  used  for 
drying  must  be  sterilized  before  use.    (See  Asepsis.) 

In  a  few  cases  the  continuity  of  the  canal  has  been  lost  because  it 
has  become  involved  in  caries  upon  one  side  of  the  root.  This  may 
be  treated  as  described  on  page  354. 

Discoloration  of  the  Teeth  by  Moist  Gangrene. — In  the  final  decom- 
position of  the  pulp  a  pigment  molecule  is  formed,  which,  entering 
the  tubules  or  formed  in  it,  stains  the  dentin  and  imparts  an  abnormal 
color  to  a  portion  or  nearly  all  of  the  crown,  which  ranges  from 
an  almost  imperceptible  loss  of  translucency  to  a  yellow-brown, 
slate-gray,  or  bluish-black  color.  Also  in  conditions  of  venous 
hyperemia  or  pulpitis,  with  which  venous  hyperemia  (stasis)  is 
associated,  the  escape  of  the  red  corpuscles  into  the  tissue,  their 
disintegration,  and  the  solution  of  the  hemoglobin  then  occurs,  and 
the  solution  enters  the  tubules,  staining  the  dentin  a  pink  color, 
which  soon  passes  into  a  purplish  rose,  and  finally  becomes  bluish- 
black  or  slate-gray. 

Those  cases  resulting  in  the  yellowish  or  brownish  coloration  are 
usually  associated  with  the  loss  of  the  pulp  in  comparatively  sound 
or  totally  sound  teeth,  the  loss  occurring  probably  through  trauma- 
tism or  through  slow  atrophic  changes,  such  as  occur  in  the  forma- 
tion of  pulp  nodules,  secondary  dentin,  apical  constriction,  etc. 
Apical  abscess  is  often  much  delayed,  but  sometimes  occurs,  showing 
that  pulp  decomposition  or  a  later  infection  has  occurred.  The 
demonstration  by  Hopewell-Smith  of  fibrosis  of  the  pulp  and  the 
obliteration  of  vascular  structures  may  account  for  a  lessened  vas- 
cularity, and  the  absence  of  the  production  of  iron  sulphid  because 
of  the  absence  of  necessary  putrefaction  and  the  production  of  the 
hematoidin  products,  as  shown  below.  The  first  class  of  cases  occurs 
either  in  sound  teeth  in  which  the  pulps  have  died  by  traumatism, 
or  in  filled  teeth  with  pulps  not  exposed,  or  in  teeth  the  pulps  of  which 
are  exposed  to  the  fluids  of  the  mouth,  permitting  putrefactive 
agencies  and  extraneous  coloring  or  color-setting  materials  to  enter. 
This  discoloration  is  most  rapid  in  the  exposed  cases. 

These  color  changes  are  rationally  explained  by  Kirk^  as  due  to 
the  decomposition  products  of  hemoglobin  existing  in  the  pulp  at 

1  American  Text-book  of  Operative  Dentistry. 


506  GANGRENE  OF  THE  PULP 

the  time  of  its  death,  and  having  an  analogue  in  the  pigmentary 
degeneration  occurring  in  the  hemoglobin  in  a  bruise  (extravasation 
of  blood),  in  which  the  part  becomes,  first,  "black  and  blue,"  then 
passes  through  a  series  of  color  changes,  in  which  yellow,  green,  and 
bluish-black  are  notable.  These  are  due  to  new^  chemical  compounds 
which  crystallize  in  the  tissue.  These  compounds  are  divided  into 
two  classes:  Hemosiderins,  or  those  containing  iron,  and  hema- 
toidins,  those  without  it.  Each  class  of  these  has  several  distinct 
substances  in  it,  each  having  its  own  color  molecule. 

Kirk  states  that  methemoglobin  is  brownish-red,  hemin  bluish- 
black,  hematin  dark  brown  or  bluish-black,  and  hematoidin  orange. 

Jakob  (Stengel)  gives  light  pea-green  and  brownish-red  as  the 
colors  of  hematoidin  for  an  old  hemorrhagic  focus,  showing  a  prob- 
able slight  chemical  variation  in  the  composition  of  the  color  molecule. 

As  the  color  changes  in  a  bruise  are  effected  under  aseptic  con- 
ditions, and  usually  the  colors  finally  produced  are  lighter  than 
the  "black  and  blue"  first  resulting,  it  is  rational  to  suppose  that 
the  yellowish  or  brownish  discoloration  of  teeth  results  under  such 
conditions  of  aseptic  decomposition  (probably  autolysis).  These 
colors,  as  remarked  by  Kirk,  are  more  or  less  permanent. 

When  a  permanent  or  progressively  darkening  slate-gray  or 
bluish-black  color  is  produced,  it  is  considered  by  Kirk  to  be  due  to 
the  formation  of  iron  sulphid  or  an  analogous  product  in  which  iron 
and  sulphur  are  constituents,  and  that  it  is  analogous  to  the  black 
discoloration  occurring  in  the  visceral  walls  of  animals  undergoing 
putrefactive  decomposition.  The  iron  is  liberated  from  the  hemo- 
globin present  by  putrefaction,  and  combines  with  the  ammonium 
sulphid  which  is  formed  from  the  ammonium  and  hydrogen  sulphid 
produced  by  the  putrefactive  decomposition.     (Fig.  480.) 

Treatment. — The  treatment  of  discolorations  consists  in  what  is 
known  as  the  bleaching  process,  which  means  the  reduction  of  the 
color  molecule  to  another  chemical  molecule  which  is  colorless,  and 
then  washing  that  out  of  the  tubules.  This  is  usually  done  by  the 
use  of  chemicals  which  directly  supply  a  molecule  of  nascent  oxygen 
when  coming  in  contact  with  the  putrefactive  material  or  its  product, 
the  color  molecule;  or  which,  as  chlorin,  abstract  hydrogen  from 
the  water  present  and  so  liberate  a  molecule  of  nascent  oxygen, 
which  combines  with  the  color  molecule.  These  are  direct  or  indirect 
oxidizing  agents,  the  effect  being  the  same,  i.  e.,  an  oxidation  of  the 
color  molecule.  A  second  class,  as  sulphurous  acid,  which  abstract 
oxygen  from  the  color  molecule,  are  called  reducing  agents,  and  may 
be  effective  when  the  oxidizmg  agents  fail. 

In  the  use  of  bleaching  agents  the  canal  should  have  been  cleansed 


MOIST  GANGRENE  OF  THE  PULP  507 

and  disinfected  with  a  simple  aqueous  solution  of  formalin  or  25  per 
cent,  ethereal  pyrozone,  or  an  aqueous  solution  of  hydrogen  dioxid, 
or  with  sodium  dioxid,  or  kalium-natrimn  alloy,  all  oils  or  other 
materials  likely  to  complicate  the  color  molecule  being  avoided.  With 
the  exception  of  formalin,  these  are  also  bleaching  agents  and  to  an 
extent  aid  the  subsequent  operation.  Formalin  would  best  be  avoided 
in  cases  of  recent  pulp  death,  as  it  may  harden  the  undecomposed 
fibrils  in  the  dentin.  The  upper  half  or  two-thhds  of  the  canal  should 
then  be  filled  with  gutta-percha  or  oxychlorid  of  zinc,  lea\'ing  the 
crown  and  one-third  of  the  root  dentin  to  be  bleached. 

After  accurate  rubber  damming  the  most  valuable  and  facile 
method  consists  of  wiping  out  with  a  strong  alkali  as  sodium  dioxid 
solution,  etc.,  and  placing  a  pellet  of  cotton  saturated  with  25  per 
cent,  ethereal  pyrozone  in  the  pulp  chamber  and  sealing  it  after 
careful  drying  of  the  lingual  tap  or  cavity  orifice  by  dropping  soft, 
quick-setting  cement  upon  the  margin  and  sealing  the  entire  tap. 

The  rubber  dam  should  not  be  removed  until  the  cement  has  set, 
as  the  ether  or  oxygen  gas  may  cause  it  to  bulge  or  blister.  This  is 
then  allowed  to  have  twenty-four  or  even  more  hours  of  action,  when, 
if  necessary,  it  may  be  removed.  The  operation  may  be  watched  at 
the  first  or  the  second  sitting  if  desired,  though  it  may  be  somewhat 
prolonged. 

Aqueous  25  per  cent,  pyrozone  may  be  made  by  shaking  together 
in  a  test-tube  one  volume  of  distilled  water  and  two  volumes  of 
25  per  cent,  ethereal  pyrozone  and  evaporating  the  ether,  the  H2O2 
being  left  in  aqueous  solution;  the  addition  of  sodium  acetate  or 
sulphate  assists  the  passage  of  the  current.  This  is  introduced  by 
means  of  the  cataphoric  current,  the  positive  pole  being  in  the  tooth, 
the  negative  at  the  hand.  Occasionally  the  reversal  of  the  pole 
succeeds  after  failure,  the  tubular  contents  probably  being  discharged 
with  the  H2O2  present  in  them. 

Oxygen  may  be  liberated  from  sodium  dioxid  (Na202)  by  sulphuric 
acid.  A  saturated  solution  of  sodium  dioxid  is  made  by  surrounding 
a  small  beaker  containing  about  2  drams  of  distilled  water,  with 
cracked  ice.  When  cold  the  sodium  dioxid  powder  is  to  be  slowly 
dusted  into  it  until  it  assumes  a  semi-opaque  appearance,  indicating 
saturation.  In  use  the  dried  dentin  is  saturated  with  it,  asbestos 
fiber  being  used  to  carry  it  to  place,  and  10  per  cent,  sulphuric  acid  is 
used  to  produce  the  liberation  of  oxygen  with  the  following  equation : 
Na202  +  H2SO4  =  Na2S04  +  H2O2. 

The  effervescence  forces  the  tubular  contents  out.  The  sodium 
dioxid  acts  upon  putrefactive  material,  decomposing  it,  and  also 
saponifies  fatty  matters. 


508  GANGRENE  OF  THE  PULP 

If  the  operation  fall  short  of  success,  this  is  due,  in  Kirk's  opinion, 
to  the  formation  of  iron  oxid,  which  can  be  removed  with  oxalic  acid 
by  sealing  a  crystal  of  it  in  the  pulp  chamber  for  twenty-four  hours. 

The  tubular  contents  being  entirely  removed  by  the  sodium-dioxid 
method,  the  tooth  is  more  translucent  than  by  other  bleaching 
methods  in  M^hich  the  bleached  organic  debris  remains  in  the  tubules. 

The  chlorin  method,  introduced  by  Truman,  depends  for  its 
efficiency  upon  the  affinity  of  chlorin  for  hydrogen,  forming  hydro- 
chloric acid  (HCl).  Finding  this  in  the  water,  it  liberates  nascent  O, 
which  oxidizes  the  color  molecule,  or,  possibly,  it  abstracts  H  from 
the  organic  matter.  The  chlorin  is  usually  evolved  from  chlorinated 
lime,  that  sold  in  paraffined  paper  cartons  or  glass  bottles  being  the 
best.  That  sold  in  metal  cans  is  often  contaminated  by  the  metallic 
chlorids. 

The  dry  powder  is  packed  into  the  cavity,  moistened  with  50  per 
cent,  acetic  acid,  and  sealed  in  with  oxyphosphate  or  temporary 
stopping  for  one  or  two  days,  and  repeated  if  necessary.  Only  vul- 
canite, bone,  ivory,  or  wood  instruments  should  be  used,  as  metal 
instruments  are  acted  upon  by  the  chlorin.  All  gold  or  metallic 
fillings  should  be  removed  for  the  same  reason,  and  if  their  removal 
would  cause  hardship  or  so  render  the  tooth  into  a  condition  indi- 
cating crowning,  either  this  should  be  done  or  the  direct  oxidizing 
method  tried. 

The  liberation  of  sulphurous  acid  may  be  induced  from  a  powder 
consisting  of  a  mixture  of  sodium  sulphite,  100  grains,  and  boric 
acid,  70  grains,  separately  desiccated  and  afterward  ground  together 
in  a  mortar,  by  acting  upon  it  with  a  drop  of  water.  The  cavity  is 
stopped  by  a  plug  of  gutta-percha  previously  prepared  and  warmed. 
The  following  reaction  occurs: 

2H3BO3  +  SNaoSOa  =  2Na3B03  +  3H2O  +  3SO2. 

In  all  the  methods,  except  the  use  of  Na202,  the  apex  of  the  canals 
should  be  sealed  before  bleaching;  after  bleaching  at  least  1  pint  of  hot 
distilled  water  should  be  forcibly  injected  into  the  tooth  to  dissolve 
out  all  products  of  chemical  action  remaining  in  the  tubules,  a  towel 
being  used  to  catch  the  drip.  The  tooth  is  then  thoroughly  dried, 
and  if  any  organic  matter  may  be  present  in  the  tubules  the  pulp 
cavity  should  be  thinly  lined  with  oxychlorid  of  zinc  to  coagulate 
it.  If  it  has  been  removed,  as  in  the  sodium  dioxid  method,  leaving 
the  tubules  empty,  they  should  be  filled  with  cavitin  varnish  after 
desiccation  to  promote  absorption,  and  the  thin  lining  then  placed. 
A  temporary  filling  is  to  be  inserted  over  this  until  success  is  evident, 


MOIST  GANGRENE  OF  THE  PULP  509 

when  the  permanent  work  is  completed  with  zinc  phosphate  and  a 
metal  filling. 

The  removal  of  metallic  stains  has  been  referred  to  on  page  238. 

Moist  Gangrene  of  Pulps  of  Temporary  Teeth. — The  same  con- 
siderations pertain  to  moist  gangrene  of  the  pulps  of  temporary 
teeth,  but  as  the  roots  are  resorbed  to  some  extent  or  are  to  be 
resorbed,  the  root  filling  should  be  of  such  a  character  as  to  permit 
its  resorption.  Probably  a  combination  of  paraffin  and  aristol  will 
best  fulfil  the  indications.  An  iodoform  paste  is  preferred  by  some. 
(See  Root  Canal  Fillings.) 

If  the  roots  be  much  resorbed,  it  is  better  to  use  a  material  which 
will  permit  venting  of  the  tooth  if  necessary.  The  canals  and  pulp 
chamber  may  be  filled  with  a  combination  of  vaselin  and  aristol,  and 
this  covered  by  a  filling.  If  trouble  arise,  a  spear  drill  is  driven  into 
the  pulp  cavity  from  a  point  beneath  the  gum  margin,  establishing 
a  vent.  The  patient  should  be  instructed  to  keep  this  open,  and  be 
furnished  a  Swiss  broach  for  the  purpose. 

At  an  age  w^hen  the  permanent  tooth  will  shortly  thereafter  erupt, 
extraction  of  the  temporary  tooth  is  often  to  be  preferred  to  treat- 
ment. 

Root-canal  Work  in  Cases  of  Gangrenous  Pulps  Involving  Future 
Consideration. — In  some  cases  of  doubtful  root  sterilization  or  filling, 
and  in  which  crowning  by  means  of  dowelled  crowns  is  a  necessity, 
provision  may  be  made  for  future  relief  or  treatment  by  the  employ- 
ment of  one  of  two  excellent  methods  of  procedure : 

1.  Kirk  has  suggested  that  the  post  and  band  of  a  Richmond  crown 
be  painted  while  warm  with  a  solution  of  gutta-percha  in  chloroform. 
The  solvent  evaporates,  leaving  a  coating  of  gutta-percha.  This 
should  be  reasonably  thick.  The  crowTi  is  then  tried  in  the  wet  root 
and  later  all  being  dried  it  is  set  with  cement.  By  warming  the  crown 
with  a  hot  crown-setting  tool  (How)  or  copper  ball  or  perhaps  forceps, 
it  may  be  removed  without  destruction  of  the  piece.  Bridges  so  set 
are  very  firm.  To  insure  removal  of  shell  cro^^^ls  their  undercut 
should  be  filled  with  gutta-percha  and  the  piece  set  after  trial.  The 
crown  may  be  set  with  gutta-percha  alone  or  in  some  cases  with 
temporary  stopping. 

2.  Girdwood  (Edinburgh)  has  suggested  root  intubation,  the  tube 
being  closed  at  the  end  with  temporary  stopping  and  then  set  with 
cement.  Immediately  thereafter  the  temporary  stopping  and  soft 
cement  are  removed  with  Donaldson  cleansers,  leaving  the  root 
lumen  free  to  the  apical  foramen  or  root  filling.  The  tube  and  canal 
are  then  treated  as  a  continuous  root  canal  would  be.  The  idea  is 
also  applied  to  a  Richmondi  or  all-porcelain  crown,  the  tube  being 


510  GANGRENE  OF  THE  PULP 

used  in  place  of  the  pin,  and  allowed  to  extend  through  the  backing, 
to  be  later  filled  as  desired. 

In  certain  cases,  as  after  removal  of  artificial  cro^vns  for  root  treat- 
ment, or  during  construction  of  new  ones,  a  temporary  crown  is  needed 

1.  A  cross-pin  facing  is  adjusted  to  the  labial  cervix  only;  a  soft 
German  silver  wire  is  adjusted  to  the  canal,  notched  at  the  line  of 
the  pins;  the  pins  bent  around  in  the  notch,  asbestos  paper  wrapped 
and  wired  around  the  labial  of  the  facing,  soft  solder  and  zinc  chlorid 
solution  placed  at  the  pins  and  heat  gently  applied  to  the  asbestos 
over  a  Bunsen  burner.  A  slight  adjustment  of  the  not  too  stifle  pin 
may  be  necessary.  It  is  set  with  temporary  stopping  or  preferably 
base  plate  gutta-percha,  allowing  it  to  make  the  adaptation  and  hold 
back  the  gum.  lodin  is  first  applied  for  sterilization.  Tagger  sug- 
gested a  copper  pin  to  be  beaten  flat  at  one  end  and  this  portion 
appropriately  punched.  The  pins  are  inserted  and  soldered  as 
above  or  bent  down. 

2.  Use  a  Goslee  facing,  adjust  crown  and  pin,  try  in  together  while 
loose;  dry  both;'  cement  pin  in  crown;  apply  to  root  while  soft  for 
adjustment,  remove,  await  hardening,  set  with  gutta-percha  as  before. 
In  either  case  when  the  crown  is  recovered,  clean  and  sterilize  it  for 
future  use. 


SECTION  YII. 

DISEASES  OF  THE  PERICEMENTUM. 

CHAPTER  XVL 
PERICEMENTITIS. 

Classification  — The  pericementum,  is  the  seat  of  numerous  nutri- 
tive and  functional  disturbances,  which  may  be  grouped,  according 
to  their  causes,  into  septic  and  non-septic. 

The  term  pericementitis  has  been  indiscriminately  applied  to  all 
affections  of  the  pericementum,  and  in  some  cases  erroneously,  for  in 
not  all  affections  of  this  structure  do  the  phenomena  of  inflammation 
appear;  in  some  hyperemia  alone  may  exist.  (See  Hyperemia  of 
Pulp.)  However,  most  of  the  acute  and  chronic  degenerations  are 
accompanied  by  evidences  of  inflammation. 

The  most  convenient  clinical  classification  of  these  disorders  is 
that  offered  by  G.  V.  Black  :^  (1)  Diseases  of  the  pericementum 
beginning  at  the  apex  of  the  root;  (2)  those  beginning. at  the  gum 
margin;  (3)  those  beginning  in  some  intermediate  portion  of  the 
pericementum.  These  may  again  be  divided,  according  to  their 
causes,  into  septic  and  non-septic.  Another  clinical  classification 
would  be  into  localized  and  general  disturbances — another  into  acute 
and  chronic. 

Evidences  of  Pericemental  Disturbance.  —  Disturbances  of  the 
pericementum  are  accompanied  by  entirely  different  symptoms 
which  serve  to  distinguish  between  them  and  diseases  of  the 
pulp.  They  are,  in  general,  tenderness  upon  percussion.  As 
shown  by  Black,^  the  pericementum  is  the  touch  organ  of  the  tooth, 
its  tactile  organ,  through  which  a  tooth  locates  force  applied  to  the 
tooth.    The  pains  of  pericemental  disturbance  are,  therefore,  in  the 

'  American  System  of  Dentistry,  vol.  i,  2  Ibid. 

(511) 


512  PERICEMENTITIS 

majority  of  cases,  exactly  localized,  instead  of  not  being  localized, 
as  in  the  case  of  the  pulp.  A  tooth  tender  upon  percussion  has 
its  pericementum  as  the  seat  of  disturbance,  at  least  there  is  a  peri- 
cemental disturbance  there  primarily  such  or  as  a  result  of  pulp 
distiu"bance.  Most  cases  of  pericemental  diseases  are  accompanied 
by  vascular  reactions  ranging  from  an  increased  blood  flow,  or  grades 
of  hyperemia  to  pronounced  inflammation,  and  have  the  corre- 
sponding symptoms.  The  increased  volume  of  the  pericementum 
causes  the  protrusion  and  loosening  of  the  tooth,  heightened  sen- 
sitivity being  the  accompaniment.  As  the  vascular  supply  of  the 
pericementum  and  that  of  the  gum  are  in  a  degree  collateral  in 
advanced  cases,  evidences  of  vascular  engorgement  may  be  seen  in 
the  gum  overlying  the  affected  tooth.  Owing  to  the  altered  density 
of  the  parts  surrounding  the  tooth  root,  percussion  upon  the  tooth 
elicits  a  different  sound  from  that  observed  in  health — the  sound  is 
dull.  The  general  symptoms  of  pericemental  affections  are,  therefore, 
tenderness  upon  percussion  and  a  dull  percussion  note,  more  or  less 
protrusion,  and  looseness  of  the  tooth  and  a  deepening  of  the  local 
gum  color,  but  in  cases  of  granuloma  and  blind  chronic  apical 
abscess  there  may  be  no  subjective  or  local  symptoms  of  distiu-b- 
ance  cognizable  to  patient  or  operator.  Hopewell  Smith^  has 
claimed  that  there  is  no  appreciable  movement  of  normal  teeth  "in 
their  articulations."  There  is  against  this  the  clinical  fact  of  move- 
ment with  steel  wedges,  by  inflammation,  etc.,  which  are  merely 
exaggerations  of  the  normal  and  the  dull  note  obtained  by  strikmg 
a  normal  tooth  as  compared  with  the  sharp  note  obtained  from  an 
implanted  tooth  in  which  bony  fixation  occurs  with  perhaps  penetra- 
tion of  slightlv  resorbed  cementum  by  newly  formed  bone. 


DISEASE  OF  THE  PERICEMENTUM  BEGINNING   AT  THE  APEX. 

Diseases  of  the  pericementum  beginning  at  the  apex  of  the  root 
are  of  two  classes,  septic  and  non-septic.  The  septic  cases  are  almost 
invariably  the  sequel  to  necrosis  of  the  pulp,  at  least  in  one  root  of  a 
multirooted  tooth,  by  suppuration  or  gangrene,  the  canal  being  septic 
or  arise  in  consequence  of  infection  through  the  canals  of  pulpless 
teeth.  The  non-septic  cases  are  due  to  mechanical  and  chemical 
irritation,  and  in  rare  cases  to  undiscovered  causes. 

Septic  Apical  Pericementitis;  Apical  Abscess. — ^Definition. — By 
septic  apical  pericementitis  is  meant  an  inflammation  of  the  apical 

J  Dental  Cosmos,  May,  1918,  page  426. 


DISEASE  OF  PERICEMENTUM  BEGINNING  AT  APEX     513 

pericementum  due  to  the  entrance  of  bacteria  into  the  tissue  lying 
in  the  apical  space. 

The  apical  tissue  may  actively  resist  a  comparatively  mild  or  so- 
called  non-virulent  infection,  such  as  due  to  Streptococcus  viridans 

Fig.  490 


Alveolar  abscess  pointing  externally.      The  abscess  is  caused  by  the  only-slightly- 
impacted  and  not-malposed  lower,  third  molar.     (Raper). 

and  may  proliferate  by  cell  multiplication  into  a  more  or  less  solid 
mass  of  soft  tissue  known  as  a  granuloma  or  the  tissue  may  be  rapidly 
broken  do^^m  into  pus  through  suppurative  inflammation  due  to  more 
virulent  infection,  a  condition  kno^^^l  as  acute  apical  abscess.  The 
33 


514  PERICEMENTITIS 

granuloma  may  develop  an  acute  phase  later  or  may  contain  a  small 
chronic  abscess  within  itself.  It  will  be  considered  later  on. 
Naturally  there  may  be  gradations  in  these  two  classes  of  reactions. 

Causes.- — ^The  most  common  causes  of  acute  septic  apical  peri- 
cementitis and  chronic  septic  apical  pericementitis  are: 

1.  Bacteria  engaged  in  the  putrefaction  of  a  gangrenous  pulp. 
The  gases  and  toxic  products  evolved  by  the  process  also  cause 
much  irritation. 

2.  Pyogenic  organisms  engaged  in  the  production  of  suppuration 
of  the  pulp  in  its  later  stages. 

3.  Pyogenic  organisms  introduced  into  the  otherwise  aseptic  tissues 
of  the  apical  space  by  means  of  instrumentation  or  other  lack  of 
aseptic  precautions,  or  if  asepsis  has  been  observed  in  root  filling  a 
later  sepsis  may  occur  via  spaces  about  the  root  filling. 

4.  An  acute  outbreak  from  a  true  blind  abscess  or  granuloma  which 
will  be  later  described  mider  the  heading  of  chronic  abscess,  (page  555.) 

5.  Infection  of  an  apical  space  by  an  abscess  arising  in  some  con- 
tiguous part  and  extending  in  the  direction  of  the  apical  space  under 
consideration.    Even  antral  empyema  caused  by  sinusitis  may  do  this. 

6.  Septic  infection  from  a  pyorrhea  pocket  located  upon  the  side 
of  the  tooth  in  question,  the  deepest  portion  of  which  approximates 
the  apical  space.  This  may  act  in  two  ways:  (1)  by  direct  infection 
of  apical  tissue  from  the  pocket;  (2)  by  pulp  infection  abscess  subse- 
quently appearing  (a  Class  I  case). 

7.  Possible  infection  by  way  of  the  pericemental  tract  from  the 
gum  margin  which  infection  may  cause  a  pericemental  abscess 
located  in  the  apical  tissue.  The  pericemental  abscess  in  this  location 
seems  rare  and  differs  as  a  cause  of  apical  abscess  from  Class  YI  cases 
only  in  having  an  apparently  unbroken  gum  margm.  If  such  an 
openmg  exist,  no  matter  how  puzzling  it  is  a  Class  VI  case. 

8.  Occasionally  a  suppiuation  following  a  severe  fracture  of  the 
alveolar  process  might  include  the  apical  tissue  as  sometimes  acute 
apical  abscess  follows  such  a  fracture. 

9.  Infection  by  way  of  the  circulation,  as  for  example,  in  influenza 
or  tonsillitis,  in  which  the  bacteria  are  in  the  blood  or  from  some 
other  focal  infection  (see  page  557).  The  theory  is  that  said  bacteria 
locate  in  the  apical  tissue  of  perhaps  properly  treated  roots  and  cause 
effects.  It  is  noted  that  at  times  when  colds  or  tonsillitis  are  general, 
usually  in  changeable  weather  and  temperatures,  abscesses  appear 
more  frequently.  A.  D.  Black^  comments  that  this  is  due  to  infective 
attack  ma  the  chculation  upon  quiescent  granulomata. 

1  Joiirnal  of  Allied  Societies,  1917. 


DISEASE  OF  PERICEMENTUM  BEGINNING  AT  APEX     515 

Apart  from  these  causes  infective  inflammation  of  apical  tissue 
does  not  seem  to  occur.  It  is  to  be  remembered  that  a  small  portion 
of  gangrenous  pulp  beneath  a  root-canal  filling  is  equivalent  to  an 
entire  gangrenous  pulp  as  a  cause  of  pericementitis.  The  vast 
majority  of  cases  occiu-  as  a  sequel  to  putrefaction  of  the  pulp, 
either  before  or  after  instrumentation,  or  as  a  result  of  infection  of 
the  apical  tissue  by  instruments  either  unsterilized  or  reinfected  by 
contact  with  the  oral  fluids,  septic  fingers,  etc. 

The  organisms  found  in  acute  apical  abscesses  are  those  usually 
found  in  gangrenous  and  suppurating  pulps,  and  in  a  certain  per- 
centage of  even  healthy  mouths.  Schreier  found  the  Diplococcus 
pneumoniae  in  15  out  of  20  cases  examined.  He  also  found  Staphy- 
lococcus pyogenes  albus  and  aureus,  and  occasionally  Streptococcus 
pyogenes.     Streptococcus  viridans  is  also  found. 

Arkovy  found  the  Bacillus  gangrense  pulpse  in  a  number  of 
cases.  These  are  virtually  the  same  organisms  that  are  found  in  the 
deeper  portions  of  a  suppurating  or  gangrenous  pulp;  this  fact 
in  itself  is  enough  to  show  the  continuity  of  infection  from  the 
pulp  canal. 

The  large  number  of  blind  abscesses  and  granulomata  found  on 
painless  devitalized  teeth  by  radiography  as  compared  with  but 
occasional  cases  of  acute  abscess  seems  to  show  that  many  of  the 
latter  are  Class  IV  cases  and  that  the  infections  are  resisted  by  the 
tissues  until  some  increased  virulence  or  lessened  resistance,  or  perhaps 
added  infection  (Class  III  or  Class  IX)  occurs.  Clinically  in  a  number 
of  cases  a  hard  bite  producing  pains  had  started  acute  symptoms 
presumably  through  compression  of  a  granuloma  with  disturbance 
of  its  balance  of  resistance  to  infection.  It  is  sometimes  difficult 
to  distinguish  between  a  non-septic  apical  pericementitis  and  a  septic 
apical  pericementitis  if  no  pus  is  present;  if,  however,  pus  is  produced 
resulting  in  an  acute  suppurative  process  the  condition  of  acute 
apical  abscess  is  produced  to  which  the  following  description  refers. 

Pathology,  Morbid  Anatomy,  and  Symptoms. — ^The  Inflammatoey 
Stage. — As  in  abscess  elsewhere  there  is  first  infection  by  pyogenic 
organisms  which  produce  the  phenomena  of  infective  inflammation 
within  the  substance  of  the  apical  tissue,  and  in  the  later  stages  in 
the  contiguous  tissues.     (See  page  41.) 

Following  the  infection,  arterial  hyperemia  is  produced,  sensation 
is  exalted,  and  the  tooth  becomes  tender  upon  percussion;  but  if 
forcibly  pressed  upon — i.  e.,  if  the  arteries  be  compressed— the 
hyperemia  is  momentarily  lessened  and  the  pressure  brings  a  sense 
of  relief.  At  this  stage  the  gum  over  the  apex  looks  normal,  but 
may  respond  to  pressure. 


516 


PERICEMENTITIS 


Following  the  arterial  hyperemia,  the  venous  obstruction  which 
ends  in  stasis  is  inaugurated  and  diapedesis  of  leukocytes  and  fibrin- 
ous exudation  into  the  intervascular  tissue  occurs.  The  fixed  cells 
undergo  proliferation.     (See  page  36.) 

As  this  condition  of  inflammation  becomes  established  the  pain  due 
to  pressure  upon  the  sensory  nerves  becomes  of  a  violent  throbbing 
character,  accompanied  by  a  sense  of  fulness.  The  swelling  of  the 
tissue  about  the  apex  of  the  root,  due  to  the  excess  of  fluid,  blood, 
leukocytes,  and  tissue  cells,  of  necessity  pushes  the  tooth  from  its 

Fig.  491 


Showing  the  morbid  anatomy  of  septic  apical  pericementitis  (acute):  A,  pus;  B, 
area  of  dying  leukocytes;  C,  septic  matter  in  root  canal;  D,  inflammation  of  process 
(osteomyelitis;  area  of  lesser  infiammation) ;  E,  swollen  periosteum  and  gum,  hyper- 
emic;  F,  alveolar  bone  in  a  stage  of  hyperemia;  G,  pericementum  at  edge  of  necrosis. 


socket,  so  that  it  feels  and  is  longer  than  the  other  teeth.  INIoreover, 
as  it  is  bitten  upon  the  apical  tissue  is  further  irritated.  The  tooth  is 
loosened  and  percussion  induces  pain  and  elicits  the  dull  note  which 
is  diagnostic  of  the  increase  of  bulk  in  the  pericementum.  The  color 
of  the  gum  over  the  root  becomes  deepened. 

First  Stage  of  Pus  Formation. — ^The  central  area  of  the  apical 
tissue — i.  e.,  that  next  the  apical  foramen  or  small  areas  nearb}^ — is 
broken  down  into  pus,  some  of  which  enters  the  root  canal  (Fig.  491, 
A).  As  the  area  of  pus  formation  widens  much  of  the  apical  tissue  is 
liquefied  (Fig.  493,  a),  though  the  fibers  are  quite  persistent.    From 


DISEASE  OF  PERICEMENTUM  BEGINNING  AT  APEX     517 

a  clinical  point  of  view  the  abscess  is  incipient  when  inflammation 
of  the  apical  tissue  next  to  the  foramen  is  profound,  and  pus  formation 
has  just  begim  (Fig.  491).  The  first  stage  continues  while  the  pus  is 
in  the  apical  tissue. 

The  surrounding  tissues  are  necessarily  inflamed,  reddened  and 
swollen  in  proportion  to  the  extent  of  pus  formation.  Even  when  the 
pus  is  still  in  the  apical  space  the  gimi  and  immediately  sm-rounding 
lip  or  cheek  tissue  may  be  inflamed,  but  often  no  such  dhect  evidence 
may  be  obtained  even  when  pus  is  evacuated  via  the  canal. 


Fig.  492 


Fig.  493 


Abscess  on  crowned  root.     (Radiograph 
by  Lodge.) 


Acute  abscess  in  second  stage.  Tooth 
opened  at  b  for  treatment,  making  an 
abscess,  discharging  via  the  canal.  (Black.) 


Fig.  494 


Fig.  495 


A  cyst  extending  from  left  lower  second  bicuspid  to 
the  central  of  same  side.  The  central  has  a  root  filling. 
In  absence  of  other  things  this  may  be  regarded  as  the 
origin  of  the  cyst. 


Method  of  accurately   de- 
termining length  of  root. 


Second  Stage  of  Pus  Formation. — ^The  bone  cells  become 
involved  in  the  process  and  are  destroyed  (osteitis).  The  throbbing 
pain,  tlie  extrusion,  looseness,  and  dulness  to  percussion,  and  the 
inflammation  and  edema  of  the  contiguous  tissues  are  marked.    The 


518 


PERICEMENTITIS 


Fig.  496 


gum  is  widely  inflamed,  reddened,  and  swollen,  but  no  demarcation 
of  an  abscess  may  be  noted  upon  the  gum  at  this  stage.  The  mem- 
branes of  the  adjoining  teeth  become  irritated  and  hyperemic,  and 
they  may  exliibit  tenderness  upon  percussion  and  their  pulps  may 
show  evidence  of  arterial  hyperemia.  There  may  be  a  fair  involve- 
ment of  surrounding  tissues. 

Third  Stage  of  Pus  Formation. — The  pus  continues  to  form 
in  all  directions  until  the  bone  is  perforated  at  some  point- — i.  e., 
usually  through  the  labial   alveolar  plate  —  that  being  the  thin- 
nest   and    most    readily  per- 
forated.    The    periosteum    is 
now  raised  and  with  the  gum 
tissue  directly   involved   as  a 
boundary  to  the   pus,    which 
collecting  beneath  it,  raises  it 
into    a    distinctly    demarked 
tumefaction  (Fig.  496,  h).  The 
pain  becomes  less  acute,  owing 
to  the  binding   resistance    of 
the  gum  being  less  than  that 
of    the   bone.      At    first    the 
swelling    is    hard,     and     this 
represents  a  mass  of  gum  tis- 
sue   overlying   pus;    later,    it 
softens  at  its    highest    point, 
pus  appears  as  a  yellow  spot 
beneath    the    mucous    mem- 
brane.     The    mucous    mem- 
brane bursts  and  a  discharge 
of  pus  follows.     The   inflam- 
mation   and  tenderness    then 
largely  subside,  but  some  de- 
gree of  looseness  and  protru- 
sion remains. 
During  the  latter  part  of  the  second  and  in  the  third  stage  of  pus 
formation,  instead  of  the  swelling  extending  but  little  beyond  the 
overlying  gum,  the  tissues  of  the  lips,  cheeks,  or  neck  may  be  very 
much  swollen  and  with  upper  teeth  the  eye  of  the  affected  side 
injected.     In  some  cases  the  outer  skin  may  become  reddened  and 
dusky,  exhibiting  the  evidences  of  extension  of  the  inflammatory 
process  far  from  its  original  site. 

The  inflammatory  process  spreads  out  from  the  central  focus  of 
pus  formation,  there  being  around  the  pus  a  zone  of  active  inflamma- 


Acute  alveolar  abscess  of  a  lower  incisor  in 
the  third  stage,  with  pus  cavity  between  the 
bone  and  the  periosteum:  a,  pus  cavity  in 
the  bone;  h,  pus  between  the  periosteum  and 
bone;  c,  lip;  d,  tooth;   e,  tongue.   (Black.) 


DISEASE  OF  PERICEMENTUM  BEGINNING  AT  APEX     519 

tion  or  stasis;  about  this  one  of  a  lesser  degree  of  inflammation,  also 
full  of  leukocytes;  about  this  an  area  of  arterial  hyperemia  or  the 
first  stage  of  inflammation,  and  around  this  normal  tissue.  These 
areas  are  not  sharply  defined,  but  merge  into  one  another  (Fig.  491, 
B,  D,  E,  F). 

In  this  way  the  contiguous  area  of  the  alveolar  bone  and  the  soft 
tissues  of  the  face  become  involved  in  the  process,  being  discolored 
and  tumefied  in  proportion  to  the  extent  of  the  pus  formation  and 
the  inflammatory  reaction  thereto,  the  facial  swelling  is  largely  due 
to  inflammatory  exudate  into  subcutaneous  cellular  tissue  spaces 
and  a  better  idea  of  the  possibility  can  be  obtained  by  a  considera- 
tion of  the  facial  emphysema  described  on  page  504.  This  swelling 
may  be  very  great  even  with  a  moderate  amount  of  pus. 

While  in  the  vast  majority  of  cases  the  direction  taken  by  the  pus, 
and  the  point  at  which  it  finds  exit,  is  the  buccal  or  labial  aspect,  and 
immediately  over  the  root  apex  of  the  affected  tooth,  or  near  it, 
these  being  the  directions  of  least  resistance,  other  anatomical  con- 
ditions or  histological  peculiarities  may  make  the  direction  of  least 
resistance  in  some  other  path  (Figs.  497  to  501). 

Instead  of  the  circumscribed  suppuration  described  as  the  ordinary 
course  of  abscess  formation  about  the  apices  of  roots  (septic  apical 
pericementitis)  which  accompanies  infection  by  the  staphylococci, 
clinical  evidences  of  infection  by  streptococci  occasionally  appear. 
The  inflammatory  process,  instead  of  being  circumscribed,  is  diffuse; 
the  inflammation  extends  along  the  lines  of  the  connective  tissues 
and  of  the  lymphatics;  the  connective  tissues  are  swollen,  the  swelling 
extending  to  the  tissues  of  the  cheek,  down  the  neck,  and  even  to 
the  shoulder — a  phlegmonous  inflammation.  Instead  of  the  com- 
paratively free  flow  of  pus  which  follows  incision  of  the  swelling  in 
ordinary  abscess,  pus  formation  in  streptococcus  infection  is  seen, 
upon  incision,  to  be  limited  and  seropurulent.  While  in  alveolar 
abscess  of  the  ordinary  types  evidences  of  septic  intoxication  or 
poisoning  are  unusual,  the  lymphatics  being  blocked,  as  a  rule,  by 
the  inflammatory  exudates,  septic  intoxication  and  poisoning  are  the 
rule  in  the  erysipelatous  cases,  those  probably  due  to  streptococcus 
infection;  bacterial  poisons  being  taken  up  by  the  lymphatics  find 
their  way  into  the  circulation. 

The  symptoms  of  the  absorption  of  bacterial  products  from  the 
circumscribed  abscesses  are:  Fever,  often  ushered  in  by  a  distinct 
chill.  The  pulse  increases  in  volume  and  tension;  it  is  full,  hard, 
and  frequent.  The  tongue  is  coated,  the  bowels  constipated.  The 
patient  is  also  weakened  and  made  irritable  by  pain  and  attendant 
loss  of  sleep  and  appetite. 


520  PERICEMENTITIS 

In  the  streptococcal  infection  there  is  danger  that  these  may 
change  into  the  more  profound  symptoms  of  septicemia — i.  e.,  a 
soft,  frequent  pulse,  repeated  chills,  diarrhea,  clammy  skin,  general 
depression,  and  a  disordered  nervous  system. 

In  multirooted  teeth  the  inflammation  and  abscess  frequently 
appear  on  only  one  root.  If  the  case  be  seen  early,  before  the  active 
exudation  period  of  the  inflammation  sets  in,  the  sjTnptoms  may  be 
clearly  localized  in  one  root,  the  tooth  exhibiting  tenderness  upon 
pressure  over  the  affected  root,  but  not  upon  the  opposite  side;  in  other 
cases  more  than  one  root  are  in^'oh'ed.  Radiography  is  a  more  certain 
guide  but  is  confused  in  some  cases  especially  upper  molars. 

After  spontaneous  discharge  of  the  pus  from  an  abscess,  the 
condition  remaining  is  that  of  an  ulcerous  surface  (the  abscess 
boundaries)  which  is  being  continuously  infected  from  the  putrescent 
pulp  remnants.  The  conditions,  it  is  seen,  are  not  like  those  of 
ordinary  abscess,  where  the  infective  material  is  largeh^  discharged 
in  the  pus  evacuation,  and  the  cells  bounding  the  abscess  wall 
dispose  of  remaining  bacteria,  so  that  regeneration  of  tissue  occurs. 
Spontaneous  healing  of  an  apical  abscess  is  the  exception;  the 
embryonic  tissue  lining  the  abscess  walls,  being  continuously  infected, 
degenerates  and  dies  as  fast  as  it  forms,  leaving  a  condition  known 
as  chronic  apical  abscess,  which  will  later  be  described  under  that 
heading. 

Clinical  History. — The  clinical  history  of  acute  alveolar  abscess 
may  be  divided  into  three  stages:  (1)  That  of  initial  inflammation 
and  pus  formation;  (2)  the  destruction  of  the  ah'eolar  process;  (3) 
the  passage  of  pus  through  the  periosteum  and  mucous  membrane. 
The  second  stage  is  usually  the  longest.  The  duration  of  the  disease 
depends  upon  the  readiness  with  which  the  tissues  between  the  point 
of  beginning  pus  formation  and  its  exit  yield.  When  the  pulp 
chamber  is  open  pus  may  find  exit  by  this  path,  constituting  the 
condition  formerly  known  as  blind  abscess — a  misnomer,  because  a 
blind  abscess  is  one  without  a  point  of  discharge,  without  a  fistula 
leading  to  it;  in  the  cases  discharging  via  the  canal,  the  latter  may 
be  considered  a  fistula  (Fig.  493). 

Acute  abscesses  usually  run  a  short  course,  the  inflammatory 
symptoms  being  severe  and  the  tissue  destruction  limited.  Notably 
upon  lower  molars,  and  upon  the  lingual  roots  of  upper  molars, 
the  density  and  thickness  of  bone  overlying  the  roots  may  make 
paths  of  greatly  increased  resistance,  so  that  the  destruction  of 
tissue  proceeds  along  the  line  of  the  pericementum,  the  pus  finding 
exit  at  the  neck  of  the  tooth.  It  is  rare  in  cases  of  lower  second 
molars,  and  still  more  rare  upon  the  third  molars,  that  pus  finds 


DISEASE  OF  PERICEMENTUM  BEGINNING  AT  APEX      521 


exit  over  the  apex  of  the  root,  the  dense  bone  of  the  external  oblique 
line  offering  the  greatest  resistance  (Fig.  497).  Over  any  teeth 
the  outer  fibrous  layers  of  the  external  periosteum  may  present 
unusual  resistance  to  the  perforative  advance  of  pus,  so  that  when 
the  fibers  of  attachment  of  the  periosteum  have  been  softened  by 


Fig.  497 


Fig.  498 


\ 


Abscess  upon  lower  third  molar, 
showing  the  usual  paths  of  pus  exit,  A 
and  B. 


Abscess  upon  palatal  root  of  an  upper  molar 
discharging  at  the  neck  of  the  tooth. 


Fig.   499 


the  inflammation,  and  pus  gains  entrance  between  bone  and  peri- 
osteum, it  may  travel  or  burrow  along  the  course  of  this  membrane 
(Fig.  498),  depriving  the  bone  of  its  main  nutritive  source,  so  that 
limited  necrosis  threatens.  The  roots  of  the  central  incisors  may  lie 
unusually  close  to  the  floor  of  the  nose, 
and  be  overlaid  externally  by  an  unu- 
sually resistant  layer  of  bone;  in  these 
cases  the  path  of  least  resistance  may 
be  in  the  direction  of  the  floor  of  the 
nose,  the  abscess  opening  at  that  point 
(Fig.  500),  or  the  pus  may  perforate 
the  lingual  alveolar  plate,  and,  raising 
the  periosteum  and  mucous  membrane, 
form  a  large  swelling  upon  one  side  of 
the  hard  palate. 

Vederspiel^  instances  a  case  in  which 
an  abscess  starting  upon  an  upper  third 

molar  finally  infected  the  tonsil  producing  an  abscess,  also  produced 
necrosis  of  a  portion  of  the  ramus  of  the  inferior  maxilla. 

The  root  apices  of  the  posterior  upper  teeth,  particularly  of  the 


Lower  molar  with  abscess  and 
distal  root  persistently  discharg- 
ing at  gingival  margin. 


1  Dental  Cosmos,  December,  1912. 


522 


PERICEMENTITIS 


first  and  second  molars,  may,  after  the  age  of  twenty-five  or  thirty 
be  encroached  upon  by  the  enlarging  maxillary  sinus,  or  may  naturally 
lie  in  this  position  as  in  a  skull  of  a  woman  of  twenty-two  years  in  the 
■s\Titer's  possession,  so  that  any  or  all  of  the  roots  of  these  teeth  may 
be  separated  from  the  floor  of  the  sinus  by  but  a  very  thin  lamina 
of  bone  or  only  by  periosteum  and  mucosa;  should  abscess  arise, 
upon  any  of  these  roots,  pus  discharge  into  the  antrum  would  neces- 
sarily follow.  In  these  cases  the  acute  symptoms  may  rapidly  subside, 
but  later  symptoms  of  antral  empyema  may  follow  (Fig.  501). 

Resort  to  the  use  of  poultices  upon  the  face,  for  the  relief  of  the 
pain  of  abscess  formation,  may  induce  such  a  softening  of  the  tissue 
over  which  they  are  applied  that  the  passage  of  pus  is  invited  toward 
the  exterior;  the  abscess  may  thus  open  upon  the  face  or  neck, 
producing  permanent,  disfiguring  scars  (Figs.  490  and  533). 


Fig.  501 


Alveolar  abscess  at  the  root  of  a 
superior  incisor,  discharging  into 
the  nose:  a,  large  abscess  cavity  in 
the  bone;  h,  mouth  of  fistula  on 
the  floor  of  nostril;  c,  lip;  d.  tooth. 
(Black.) 


Alveolar  abscess  at  the  root  of  an  upper 
molar  discharging  into  the  antrum  of  High- 
more:  a,  abscess  cavity  in  the  bone;  6, 
mouth  of  fistula  on  the  floor  of  the  antrum ; 
c,  pus  in  the  antral  cavity.     (Black.) 


In  patients  who  are  in  a  cachectic  condition,  who  have  an  evil 
heredity,  or  whose  tissue  resistance  is  markedly  lessened  in  conse- 
quence of  tuberculosis,  or  more  frequently  of  syphilis,  septic  peri- 
cementitis may  run  a  riotoUs  course;  the  bone  suffers  extensively  by 
direct  action;  the  periosteum  is  undermined,  is  stripped  from  the 
bone  over  large  areas,  and  breaks  down  readily;  so  that  while  in 
the  healthy  person  alveolar  abscess  formation  may  run  a  direct 
course  and  find  prompt  outlet,  in  the  debilitated  patient  extensive 
pus  infiltration,  with  necrosis,  may  occur.    Thus  an  abscess  on  a  right 


DISEASE  OF  PERICEMENTUM  BEGINNING  AT  APEX     523 


lower  molar  has  been  seen  to  dissect  its  way  around  the  entire  labial 
surface  of  the  mandible  to  the  left  side.  In  cachectic  persons  lym- 
phatic involvement  is  common;  waste  products  of  bacterial  origin 
find  their  way  into  the  lymphatics,  and  set  up  secondary  irritative 
processes  in  the  nearest  lymphatic  glands — lymphadenitis.  Acute 
systemic  toxic  effects  are  also  produced. 

In  persons  whose  oral  hygiene  is  neglected  the  third  stage  of 
alveolar  abscess  is  frequently  violent  and  the  inflammatory  process 
widespread. 

Diagnosis. — In  incipient  apical  pericementitis  the  sj'mptoms  may 
consist  of  reflex  pains,  but,  as  a  rule,  are  distinctly  localized  in  the 
teeth  aifected,  which  are  tender  to  the  touch.  The  discoloration  of 
the  tooth  crown  and  other  evidences  of  moist  gangrene  are  usually 
present  unless  the  tooth  has  been  previously  partially  treated,  when 
the  color  may  be  good,  but  by  transmitted  light  opacity  is  noted. 
In  a  few  cases  the  tooth  has  had  almost  a  normal  color  even  under 
the  transmitted  light.  As  color  is  not  always  a  guide,  electric,  thermal 
or  other  tests  for  pulp  vitality  are  in  order  in  doubtful  cases  (see 
page  483).  In  the  pronounced  cases  the  symptoms  are  as  described 
(see  page  516,  etc.). 

A  timid  patient  will  often  unintentionally  confuse  pericemental 
tenderness  with  the  pain  of  sensitive  dentin. 

In  very  doubtful  cases,  as  when  molars  have  deep  amalgam  fillings, 
or  pins  have  been  placed  in  root  canals,  or  gold  crowns  cover  the 
natural  crowns,  either  the  covering 
must  be  removed  or  preferably  a  radio- 
graph be  taken. 

After  high  inflammation  has  existed 
for  twenty-four  hours,  pus  is  generally 
present  in  the  apical  tissue. 

Of  two  pulpless  teeth  surrounded 
by  a  zone  of  inflammation,  the  more 
tender  and  loosened  is  the  one  affected, 
though  both  may  be  acting  at  once. 
It  is  to  be  remembered  that  adjoin- 
ing, otherwise  normal,  teeth  may  show 
some  evidence  of  pericementitis,  due 
to    extension,    so     that    differentiation 

is  necessary.     Fig.  543  shows  a  lateral  apparently  affected.    It  was 
drilled  only  to  find  the  pulp  alive.     This  shows  the  need  of  confirm a- 


FiG.  502 


Diagnosis  of  apical  abscess  by 
x-rays.   (Price.') 


1  Items  of  Interest,  1901. 


524 


PERICEMENTITIS 


Fig.  503 


toiy  tests  (see  page  483).  The  various  stages  of  inflammation  and 
pus  formation  are  judged  by  the  appearance  of  the  gum  or  by  the 
x-rays  (Fig.  502).  The  greater  the  swelhng  and  injection  of  the 
gum,  the  more  advanced  is  the  pus  formation. 

The  inflammatory  action  precedes  the  advance  of  pus,  which 
furnishes  a  guide  to  the  direction  the  pus  is  pursuing — viz.,  where 
the  most  intense  coloration  and  the  greatest  swelhng  appears  will  be 
the  point  at  which  the  abscess  will  point  or  discharge.  A  sudden 
subsidence  of  inflammation  without  an  immediately  discoverable 
point  of  pus  exit  should  lead  to  the  suspicion  that  the  discharge  has 
taken  place  in  an  unusual  situation. 

The  direction  pus  may  take  is  often  determined  by  gravity,  but 
the  resistance  of  certain  tissues  may  cause  the  pus  to  seek  the  easiest 
path.  Thus,  by  discharging  into  the  antrum  or  nose  it  goes  counter 
to  gravity.  In  such  cases  as  discharge  into  the  antrum  there  is 
liable  to  be  a  collection  of  pus  in  that  cavity  which  may  cause  destruc- 
tion of  the  mucous  membrane  and  bone.    This  condition  is  known 

as  empyema  of  the  antrum.  The 
sudden  subsidence  of  an  acute  abscess 
upon  a  tooth  located  beneath  the 
antrum  should  create  a  suspicion  of 
discharge  into  that  sinus.  If  a  fine 
probe  can  be  passed  an  unusual  length 
into  a  root  canal  it  indicates  this  form 
of  sinus  involvement. 

An  abscess  originating  about  an  im- 
pacted tooth,  or  one  due  to  subperio- 
steal inflammation,  must  be  differen- 
tiated^ (Fig.  503).  A  pericemental 
abscess  must  also  be  considered.  It  is 
always  more  lateral  and  there  is  less 
facial  involvement,  also  there  is  usually 
a  pyorrhea  pocket  leading  to  it.  An 
acute  abscess  of  the  pulp  in  its  most 
pronounced  stage  may  simulate  incip- 
ient or  even  pronounced  acute  apical  pericementitis,  (See  page  412.) 
An  abscess  sometimes  forms  beneath  the  flap  of  gam  overlying  a 
third  molar.  This  begins  as  an  ulceration  of  the  under  side  of  the 
flap,  but  the  pus  burrows  between  the  tooth  and  the  gum,  and  when 
well  confined  may  develop  laterally,  causing  the  formation  and  at 
least  partial  retention  of  a  quantity  of  pus  in  the  tissues  of  the  cheek. 


Non-descended  cuspid  and  lat- 
eral. These  teeth  were  entirely 
enveloped  in  pus.  The  cuspid 
and  lateral  shadows  overlie  each 
other.  Between  these  and  the 
first  bicuspid  may  be  seen  three 
tiny  supernumeraries.     (Lodge.) 


'  Black:  American  System  of  Dentistry,  vol.  i. 


DISEASE  OF  PERICEMENTUM  BEGINNING  AT  APEX     525 

This  condition  more  nearly  simulates  the  lateral  abscess  associated 
with  a  pyorrhea  pocket,  and  as  by  extension  it  sometimes  involves 
the  tonsil,  the  case  may  be  mistaken  for  an  amygdalitis. 

The  last  three  conditions  are  usually  associated  with  suspected 
teeth  containing  vital  pulps,  so  that  tests  for  pulp  vitality  are  to  be 
applied. 

In  certain  cases  of  pulp  gangrene  part  of  the  pulp  only  may  be 
dead — e.  g.,  the  lingual  filament  of  the  pulp  of  an  upper  molar;  while 
the  balance  may  be  vital  (the  buccal  filaments) .  This  fact  may  con- 
fuse the  response  to  tests  and  is  to  be  borne  in  mind  (see  page  383). 
A  broken  root  covered  more  or  less  by  gum  or  carious  bone  must  be 
taken  into  account  (Fig.  307) .  An  ulcerated  aveolar  socket  is  usually 
obvious. 

Prognosis. — The' writer  believes  that  if  proper  root  canal  work  can 
be  done  the  parts  can  be  sterilized  and  the  roots  aseptically  filled  so 
as  to  cure  an  acute  apical  abscess.  This  conclusion  is,  however,  subject 
to  the  considerations  on  pages  467  and  469.  The  futm-e  of  the  tooth 
depends  upon  the  thoroughness  with  which  sources  of  infection  may 
be  destroyed  and  permanently  removed,  and  the  completeness  with 
which  regeneration  of  tissue  can  be  induced. 

Treatment. — In  the  initial  inflammation  and  first  stage  of  pus  for- 
mation the  treatment  should  be  abortive,  to  afford  relief  from  the 
pain.  The  cause  of  the  inflammation  should  be  removed,  if  possible, 
and  the  pus  formed  be  removed  or,  at  least,  permitted  to  escape  by 
way  of  the  pulp  canals.  The  promptness  of  relief  from  pain  depends 
upon  the  thoroughness  with  which  this  is  accomplished. 

The  pulp  chamber  should  be  opened  to  an  extent  which  permits 
the  free  passage  of  broaches  into  the  canal  (Figs.  493  and  498). 

If  the  cavity  of  decay  be  open,  the  pulpal  wall  is  to  be  perforated. 
If  a  filling  be  present,  it  is  in  part  or  entirely  removed.  If  the  enamel 
be  entirel}'^  sound,  or  if  subsequent  treatment  require  a  new  opening 
in  line  with  the  pulp  canals,  it  is  at  least  in  part  made. 

These  openings  are  usually  begun  with  a  small,  spear-pointed  drill 
(No.  100,  S.  S.  W.  Catalog)  revolving  in  a  perfectly  true  hand  piece. 
To  center  the  drill,  first  spot  the  enamel  with  a  dentate  bur.  The 
opening  made  is  enlarged  with  successive  sizes  of  sharp,  round, 
dentate  burs  until  of  sufficient  size. 

According  to  the  amount  of  tenderness,  the  tooth  will  require  a 
counterpressure  to  that  of  the  drill.  If  the  entrance  be  made  through 
the  occlusal  face  of  the  tooth,  or  in  a  direction  which  would  cause 
direct  pressm-e  on  the  apical'pericementum,  a  ligature  of  the  traction 
cable  now  used  for" wedging 'with  Jong  ends  may  be  placed  around  the 
tooth,  and  traction  be^made  by  drawingon  the  loose  ends  of  the  liga- 


526  PERICEMENTITIS 

ture.^  Effective  counterpressure  against  lateral  entrance  to  the  pulp 
chamber  may  be  made  by  softening  a  small  roll  of  modeling  compound 
and  moulding  over  the  face  of  the  affected  tooth  and  several  of  those 
adjoining  it,  and  hardening  with  cold  water.  This  temporary  splint 
is  held  in  place  by  the  index  finger  of  the  left  hand.  W.  D.  Tracy 
recommends  for  posterior  teeth  a  double  modeling  compound  splint, 
one  lingual,  one  buccal,  to  be  held  with  the  fingers,  or  two  ligatures 
may  be  placed  between  the  teeth  before  the  compound  is  placed  and 
the  ends  tied  over  the  splints,  binding  them  against  the  teeth.  A  special 
clamp  raising  the  affected  tooth  can  be  had  of  J.  W.  Ivory.  In  case 
the  inflammatory  process  is  marked,  or  if  the  patient  be  in  bed,  it 
may  be  necessary  to  make  a  vent  opening  by  the  easiest  path,  espe- 
cially when  using  a  hand  drill — i.  e.,  at  the  junction  of  enamel  and 
cementum — directly  into  the  chamber. 

Watkins^  has  used  "blue  light"  applied  from  a  16-candle  power 
blue-globed  electric  lamp  through  a  funnel  directly  upon  the  part. 
He  claims  relief  from  the  pain,  enabling  him  to  open  the  tooth 
previously  too  painful  to  be  operated  upon.  He  also  claims  that 
swelling  is  much  reduced  by  it,  in  some  cases  in  twenty  minutes. 
The  high  frequency  current  is  also  useful  in  this  connection.  The 
broad  electrode  of  a  violet-ray  apparatus  is  applied  to  the  face  and 
moved  about.     (See  Chapter  on  Uses  of  Electricity.) 

Patients  do  not  ordinarily  tolerate  the  rubber  dam  in  these  cases, 
and  as  the  tooth  should  be  left  open  it  need  not  be  used. 

As  soon  as  entrance  to  the  pulp  chamber  is  effected,  the  cavity 
is  syringed  with  a  strong  antiseptic.  Fine  probes  are  passed  and 
repassed  into  the  opening  to  free  the  outlet,  so  that  gases  and  pus 
may  escape  and  fresh  portions  of  the  antiseptic  be  worked  into  the 
cavity.  The  escape  of  blood  from  the  canal  is  a  sign  that  all  the  pus 
is  vented.  The  quickness  with  which  relief  is  secured  will  depend 
upon  the  thoroughness  with  which  the  canals  are  entered  and  their 
putrid  contents  given  vent.  A  tedious  class  of  cases  are  those  in 
which  a  canal  of  a  molar  is  filled  or  partially  filled.  Unless  entrance 
to  and  cleansing  of  the  canal  be  accomplished,  the  inflammation 
will  proceed  until  the  pus  finds  external  vent.  An  hour  spent  in 
gaining  access  to  and  cleansing  such  canals  is  well  spent. 

The  patient  may  be  directed  to  make  suction  with  the  tongue 
to  create  a  vacuum  tending  to  draw  the  pus,  etc.,  into  the  canal. 
If  a  tight  joint  can  be  obtained  with  a  special  point  an  abscess  syringe 
may  have  its  plunger  drawn  back  to  create  the  vacuum.  This 
measure  is  not  necessary  when  prompt  relief  is  obtained  by  venting. 

1  J.  Foster  Flagg:  Lectures  on  Dental  Therapeutics.  ^  Dental  Cosmos,  1905. 


DISEASE  OF  PERICEMENTUM  BEGINNING  AT  APEX      527 

The  canals  may  be  dried  and  an  anodyne  antiseptic,  such  as 
phenol  camphor  plus  menthol,  pumped  into  them.  If,  now,  pro- 
vision against  mastication  upon  the  elongated  tooth  be  made  by 
means  of  a  guard,  relief  is  tolerably  certain. 

A  guard  may  be  made  from  a  strip  of  rubber  dam  two  inches  long 
and  of  a  width  corresponding  to  the  distance  from  the  buccal  to  the 
lingual  gum  margins  and  rolled  into  a  pad  of  the  width  of  the 
occlusal  face  of  the  tooth  to  be  covered.  Floss  silk  is  then  sewed 
through  this  in  such  a  manner  as  to  cause  it  to  tie  the  pad  over  the 
tooth,  the  silk  itself  encircling  the  neck  of  the  tooth. ^  This  should 
be  attached  to  a  nearby  tooth,  and  will  insure  rest  of  the  affected 
pericementum  hr  preventing  occlusion  upon  the  abscessed  tooth 
(Fig.  504). 

Fig.  504 


Rubber  dam  guard  for  use  in  pericementitis:  A,  roll  of  dam  threaded;  B,  guard  fitted 
over  tooth;  tooth  eliminated  to  show  the  manner  in  which  the  silk  encircles  it. 


The  mouth  is  to  be  frequently  washed  with  a  cold  antiseptic  (Lis- 
terine  in  hamamelis).  In  simple  cases  with  prompt  relief  this  is 
all  that  is  necessary;  in  marked  cases  the  reduction  of  the  inflam- 
matory engorgement  should  be  attempted  in  addition. 

1.  In  some  cases  application  of  cold  wet  cloths  or  an  ice-bag  to  the 
face  is  a  sufficient  addition.  In  more  marked  cases,  one  of  several 
lines  of  treatment  may  be  added.  Swedish  leeches  may  be  applied 
to  the  gum,  or  a  cut  or  two  made  in  the  gum  o^-er  the  apex  of  the 
tooth  will  allow  free  bloodletting  and  drainage  of  the  excess  of  blood 
in  the  pericementmn.  A  tablespoonful  of  magnesimn  sulphate  in  a 
goblet  of  water  or  a  bottle  (12f§)  of  citrate  of  magnesia  is  given  as  a 
derivant  and  depleti^'e.  Also  a  hot  pediluvium  with  mustard  added 
is  administered  as  a  derivant.  Quinin  in  doses  of  gr.  vj  is  given  as 
a  febrifuge  and  to  limit  exudation,  and  tincture  of  aconite,  two  drops 
at  first,  and  one-half  drop  each  half  hom-  is  given  until  the  volume, 
tension,  and  frequency  of  the  pulse  are  reduced. 

]\Iorphin  sulphate  in  blondes  and  morphin  bimeconate  in  brunettes, 
especially  those  with  blue  eyes  (or  any  persons  with  known  idio- 

1  Flagg. 


528  PERICEMENTITIS 

syncrasies  to  morphin),  may  be  administered  in  |-grain  doses,  repeated 
each  hour  up  to  f  grain,  ^^^len  great  suffering  renders  it  necessary,  a 
hypodermic  may  take  its  place.  Trigemin,  bromural  and  aspirin  are 
alternate  anodynes  after  the  bloodletting,  etc. 

2.  The  hot  pediluvium  is  to  be  administered  and  during  this  a 
portion  of  a  solution  of  10  grains  of  Dover's  powder  in  a  quantity 
of  hot  lemonade  is  drunk.  Later  when  the  patient  is  well  covered 
in  bed  the  balance  is  taken.  This  treatment  conjoins — derivation  by 
pediluvium  and  diaphoresis  and  an  anodyne. 

As  the  opium  taken  equals  |  grain  of  morphin,  if  needed  more  mor- 
phin may  be  used. 

Quinin  gr.  vj  and  the  aconite  as  before  may  be  used. 

These  several  measures  are  to  be  regarded  as  the  abortive  treat- 
ment of  alveolar  abscess ;  they  apply  to  all  cases  if  seen  early  enough, 
and  will  in  the  majority  of  cases  prevent  the  disease  passing  the 
early  inflammatory  stages,  unless  septic  matter  be  violently  thrust 
through  the  apical  foramen,  especially  of  the  one  of  a  multirooted 
tooth  which  is  not  involved. 

The  Second  Stage  of  Acute  Apical  Abscess.- — The  pus  is  in  the  bone 
and  the  infection  considered  more  virulent,  i.  e.,  the  germs  are 
especially  active.  The  abortive  treatment  should  first  be  tried,  and  if 
free  venting  of  pus  is  obtained  relief  is  usually  given.  If  not  given  the 
case  continues  to  the  third  stage.  If  bearable,  or  the  surgical  method 
be  impracticable,  a  dental  capsicum  plaster  may  be  applied  to  the 
gum  or  a  roasted  half-raisin  may  be  applied.  Either  causes  an  inflam- 
mation of  the  gum,  which  advances  the  tissue  that  much  nearer 
suppuration.  Thus  it  prepares  a  readily  invaded  tissue  and  hastens 
pointing.  The  contrary  effect  has  sometimes  been  produced,  and  is 
explained  upon  the  ground  that  the  increased  amount  of  blood 
has  increased  the  phagocytosis  and  destruction  of  bacteria  or  has 
stimulated  a  restoration  of  the  circulation,  possibly  both,  producing 
resolution.  It  is  proper  to  denominate  this  the  ex-pedant  treatment, 
and  while,  perhaps,  unsmgical,  at  times  permits  no  alternative 
except  extraction.    The  pain  is  to  be  combated  with  anodynes. 

When  tolerable  or  imperative,  the  surgical  method  of  venting  the 
abscess  through  an  opening  in  the  gum  is  valuable.  The  apical 
region  is  located  as  nearly  as  possible  by  measuring  the  length  of  the 
tooth  with  a  probe  passed  into  the  canal  and  over  which  a  small 
piece  of  rubber  dam  is  slipped  as  a  guide.  This  is  laid  over  the 
crown  and  gum  and  a  tiny  drop  of  carbolic  acid  is  placed  just  above 
the  point  of  the  probe  as  a  guide.  A  vertical  cut  is  made  in  the 
gum  down  to  the  bone,  and  a  broad  spear  drill  is  driven  through  it 
into  the  abscess  tract.     Whether  this  shall  be  done  under  ethyl 


DISEASE  OF  PERICEMENTUM  BEGINNING  AT  APEX      529 

chlorid  refrigeration,  local  or  conductive  anesthesia,  or  short  general 
anesthesia,  the  operator  must  determine. 

A  gradual  perforation  is  useful  in  some  cases.  This  method, 
designed  by  Black,  consists  in  gradually  escharing  and  scratching 
the  gum  tissue.  Successive  applications  of  just  such  phenol  as  adheres 
to  the  point  only  of  a  sharply  serrated  plugger  are  made,  followed  by 
slight  scratching  only  so  that  blood  shall  not  be  drawn.  By  repeti- 
tions the  bone  is  ultimately  reached. 

A  fresh  drop  of  phenol  is  applied,  the  periosteum  scraped  away 
slightly,  and  the  drill  then  used. 

A  Rollins  tubular  knife  (Fig.  505)  has  been  used  with  success  to 
remove  a  piece  of  gum,  after  which  the  drill  or  a  fine  trephine 
(Fig.  506)  is  used.  Some  acute  pain  may  follow  this  operation,  but 
usually-  lasts  only  a  short  time. 


Tubular  knives. 


Walker- Younger  trephines. 


If  antiseptics  are  used  to  syringe  out  the  abscess  cavity,  it  is  better 
to  use  a  mixture  of  six  parts  hamamelis  (aqueous)  and  one  part 
listerine  as  a  partial  sedative.  The  use  of  hydrogen  dioxid  is  often 
very  painful,  owing  to  the  rapid  reaction  with  the  blood  present,  and 
as  it  sometimes  also  drives  the  infective  material  into  remote  parts 
without  disinfecting  it,  its  use  in  this  connection  is  not  without 
danger,  and  should  be  avoided. 

It  has  been  a  subject  of  controversy  whether  a  tooth  should  be 
extracted  while  the  abscess  is  in  the  second  stage.  It  has  been 
claimed  that  the  continuation  of  pus  formation  after  extraction 
renders  the  state  of  the  patient  worse  than  before  extracted. 

This  occurrence  is  comparatively  infrequently  seen,  and  is,  of 
course,  due  either  to  the  retention  of  some  pyogenic  organisms 
34 


530  PERICEMENTITIS 

beneath  the  clot  which  forms  in  the  alveolus  or  the  infection  of  the 
parts  by  extraneous  organisms. 

The  retention  of  the  tooth  until  a  fistula  forms  would  also  confine 
the  bacteria  for  the  time. 

Unquestionably  metastatic  infections  have  appeared  as  the  result 
of  persistent  local  infection  following  tooth  extraction,  the  avenue 
being  the  lymphatics  or  bloodvessels ;  therefore,  in  cases  of  extraction 
during  the  second  stage  of  pus  formation  apex  of  the  alveolus  should  be 
curetted — syringed  out  with  an  antiseptic  and  a  clot  allowed  to  form. 
If  it  be  thought  desirable  to  repeat  the  syringing,  a  tent  of  antiseptic 
gauze  may  be  gently  carried  to  the  apex  of  the  alveolus  and  left.  This 
tent  may  be  removed  to  permit  syringing,  and  should  nexer  he  left  long 
at  any  one  time,  as  septic  inflammation  of  the  alveolar  walls  may  occur. 
It  also  does  not  drain  pus  readily,  so  it  might  cause  an  abscess  if 
left  too  long.    (For  curettes  see  Apicoectomy.) 

In  cases  of  this  kind  oral  sterilization  and  anti-infective  systemic 
medication  are  of  importance.  As  soon  as  improvement  is  noted  the 
tent  should  be  removed,  the  alveolus  sterilized  as  before,  and  a  new 
clot  induced  by  a  curetting  of  the  walls.  The  case  should  now  pro- 
ceed as  any  ordinary  extraction;  if  not,  it  should  be  treated  as  for 
"  dry  socket  "  (which  see). 

In  a  reply  to  a  circular  letter  of  questions  regarding  this  point, 
Black,  Kirk,  Ottolengui,  Hoffheinz,  and  Schamburg  all  favored 
extraction  as  a  means  of  removal  of  the  cause  and  as  a  less  evil  than 
allowing  the  tooth  to  remain  enclosing  the  bacteria,  which,  if  cap- 
able of  f)roducing  septicemia,  it  would  do  if  allowed  to  remain.  They 
are  therefore  in  agreement  with  the  editor's  position  taken  in  the 
second  edition  of  this  work  (1904).  Brown  argues  the  difficulty  of 
decision  in  an  individual  case.  All  are  practically  opposed  to  the 
idea  that  pneumonia  is  more  likely  to  result  from  postextraction 
sepsis  than  septicemia,  Morris^  having  taken  the  position  that 
pneumonia  resulted  from  extractions  in  this  condition.  Each  and 
all  advised  careful  ante-  and  postextraction  antisepsis. 

The  editor  has  had  quite  a  number  of  cases  of  necrosis  (necrotic 
dry  socket)  following  extractions  at  the  hands  of  specialists,  and 
believes  they  and  he  should  have  been  more  watchful  in  these  cases, 
and  that  in  most  cases  a  strong  solution  of  potassium  permanganate 
should  be  used  as  a  wash  before  and  after  extraction,  or  tincture 
of  iodin  be  locally  applied,  especially  in  cases  requiring  laceration 
of  the  gum.  Antiseptic  spraying  of  the  alveolus,  etc.,  is  a  reliable 
measure.     In  one  case  of  extraction  of  a  lower  third  molar  opera- 

1  Mitchell:  Dental  Cosmos,  1907,  p.  713. 


DISEASE  OF  PERICEMENTUM  BEGINNING  AT  APEX     531 

tion  under  anesthesia  for  prevention  of  progressive  necrosis  became 
necessary.  The  making  of  a  cautious  diagnosis  and  awaiting  the 
proper  time,  as  recommended  by  Mitchell,  is  a  physical  impossi- 
bility unless  one  await  the  third  stage  or  a  fistula  or  general  infection, 
as  in  this  state  the  bacteria  are  considered  virulent,  especially  while 
bone  solution  is  in  progress. 

The  Third  Stage  of  Acute  Apical  Abscess. — In  this  stage  the  pus 
has  found  its  way  through  or  beneath  the  periosteum  on  the  outside 
of  the  bone;  therefore  its  germs  are  engaged  in  liquefying  the  gum 
tissue  or  in  unusual  location  the  mucosa  or  muscular  tissue  of  the 
part.  Except  in  these  cases  the  gum  is  tumefied,  a  hard,  circum- 
scribed, inflamed  nodule  indicating  pus  near  the  bone,  or  a  soft,  more 
generally  diffused  swelling  indicating  more  superficially  located  pus, 
while  a  soft  yellow  or  yellowish-pink  tumefaction  indicates  pointing. 
In  all  these  cases  the  indication  is  for  a  surgical  opening  of  the  gum 
rather  than  the  opening  of  the  tooth.  The  part  should  be  gently 
disinfected  with  tincture  of  iodin  or  diluted  Talbot's  iodoglycerol  on  a 
ball  of  cotton,  and  a  sharp  bistoury  should  be  boldly  driven  to  the 
bone,  with  the  cutting  edge  turned  parallel  with  the  alveolar  bone. 
The  lip  or  cheek  is  to  be  drawn  well  away  to  avoid  injuring  the  coro- 
noid,  buccal,  or  facial  artery.  A  cut  about  a  half  to  three-quarters 
of  an  inch  in  length  is  rapidly  made  by  sweeping  the  edge  and  point 
occlusally.  Too  deep  lancing  upon  the  hard  palate  may  injure  the 
anterior  palatine  artery. 

As  this  is  usually  painful,  it  is  better  to  refrigerate  the  gum  with 
ethyl  chlorid  or  operate  under  short  general  anesthesia,  e.  g.,  nitrous 
oxid,  somnoform  or  the  first  impression  of  ether.  Novocain  is  only 
useful  in  the  case  of  deep-seated  pus  when  injected  into  the  more 
healthy  tissue  around  the  area  to  the  opened,  or  as  a  means  of  con- 
ductive anesthesia.  Next,  the  abscess  tract  is  to  be  gently  washed  out 
with  the  hamamelis  and  listerine  solution  (see  page  529),  preferably 
warmed.    Fahly  hot  water  containing  an  antiseptic  also  gives  relief. 

If  the  abscess  has  been  deep-seated  it  is  well  to  introduce  a  fine 
tent  of  antiseptic  gauze  through  the  opening  into  the  abscess  tract 
to  prevent  the  too  rapid  healing  of  the  external  orifice  which  is  apt 
to  occur,  owing  to  the  approximation  of  the  lips  of  the  wound  pro- 
duced by  cheek  pressure.  This  healing  sometimes  permits  a  second 
collection  of  pus.  The  tent  should  be  removed  not  later  than  the 
next  day,  the  abscess  tract  disinfected  again,  possibly  with  a  mer- 
curic chlorid  solution,  and  a  new  tent  placed.  The  patient  should 
always  be  cautioned  to  remove  the  tent  if  swelling  return,  as  this  . 
indicates  a  stoppage  of  the  vent,  with  collection  of  pus.  At  this  time 
the  tooth  should  be  opened  and  disinfected  if  not  tolerable  at  the 


532  PERICEMENTITIS 

first  sitting.  AYhen  this  is  tolerable  the  crown  may  be  tapped  and 
formocresol  sealed  in  the  pulp  chamber,  just  before  the  operation  of 
lancing,  in  order  to  permit  disinfection  and  thus  limit  pus  formation 
and  to  save  time. 

When  diffuse  cellulitis  with  marked  febrile  disturbance  passing 
into  the  adynamic  type  is  produced,  one  should  fear  general  infec- 
tion with  virulent  bacteria  and  treat  not  only  locally,  but  use 
blood  germicides  against  a  possible  septicemia.  In  these  cases  there 
may  be  little  pus  formed  compared  with  the  area  involved. 

As  a  preventive  of  possible  blood  infection  the  following  may  be 
administered  as  a  blood  antiseptic  and  tonic: 

I^ — Hydrargj^ri  bichloridi gr.j 

Tincturse  ferri  chloridi fSJ — M. 

Sig. — Twenty  drops  in  water  four  times  a  day. 

The  editor  employed  this  remedy  with  markedly  beneficial  effect, 
while  suffering  from  a  very  severe  abscess  about  the  finger-nail,  due 
to  infection  by  the  Streptococcus  pyogenes  and  associated  with 
lymphangitis  extending  as  a  bright  red  streak  into  the  axilla. 

If  the  adynamia  and  other  symptoms  be  progressive,  medical 
cooperation  should  be  obtained  to  divide  the  responsibility  and  to 
afford  every  means  possible  toward  the  cure.  The  extraction  of  the 
tooth  followed  by  sterilization  and  curettement  of  the  part,  and  the 
use  of  streptococcus  antitoxin  or  vaccine  conjoined  with  the 
sustention  of  the  vital  powers  by  nutritious  predigested  food  and 
alcohol  is  logical.  In  even  ordinarily  severe  cases  not  of  this  variety 
there  will  be  some  fever  due  to  the  toxin  absorbed,  and  the  pain,  loss 
of  sleep  and  appetite  will  cause  physical  debility. 

For  this  there  is  nothing  better  than  the  following,  as  tonic,  anti- 
septic, and  antipyretic: 

I^— Saloli, 

Quininse  sulphatis  (vel  hydrochloratis)        .      .      .      .    aa     gr.  Ix 
M.  et  fiant  capsulas  no.  xx. 
Sig.^Take  one  four  to  six  times  daily,  before  meals  when  near  them. 

Or,       . 

I^ — Quininae  sulphatis gr.  xxx 

Acetanilidi .       .      .      gr.  xxiv 

Caffeinse  citratis gr.  iij 

M.  et  fiant  pil.  no.  xij. 

Sig. — -One  every  hour.     (Endelmann.) 

The  facial  swelling  resolves  with  the  cure  of  the  abscess  or  its  proper 
venting,  but  may  be  assisted  by  cold  applications  or  cataplasma 
kaolini  to  the  outside  of  the  face  and  by  gentle  massage  by  the 
patient  or  nurse.      (See  pages  526  and  533.) 


DISEASE  OF  PERICEMENTUM  BEGINNING  AT  APEX     533 

As  a  means  of  reducing  hard  swellings  vibratory  massage  is  use- 
ful. A  simple  appliance  for  this  purpose,  devised  by  W.  H.  Mitchell,^ 
consists  of  a  cam-like  piece  of  metal  perforated  at  its  smaller  end  for 
mounting  upon  a  screw  mandril;  it  is  held  in  the  dental  hand  piece 
strapped  to  the  hand  as  shown.  Its  centrifugal  force  imparts  a 
vibratory  motion  to  the  hand  which  can  be  utilized  for  massage  with 
the  finger  tips,  or  by  holding  in  the  hand  an  instrument  containing 
upon  its  end  a  soft  rubber  cup.  The  part  to  be  massaged  should 
be  lubricated  with  vaselin  (Figs.  507  and  508) . 


Fig.  507 


Fig.  oOS 


W.    H.    Mitchell's   vibrator   strapped    to 
hand. 


W.  H.  Mitchell's  vibrator  and  rubber 
cup   applicator. 


The  heat  of  a  100  candle  electric  lamp  concentrated  upon  the  face 
by  a  parabolic  reflector  from  a  short  distance  and  followed  by  massage 
is  also  useful  in  facial  swellings  due  to  cellulitis.  The  high  frequency 
current  from  a  violet-ray  apparatus  is  also  useful,  fm-nishing  an 
electrical  cell  massage. 

Under  no  circumstances  should  hot  poultices  be  applied  to  the 
outside  of  the  face,  as  a  discharge  of  pus  in  that  direction  will  cause 
a  disfiguring  scar.  If  an  abscess  threaten  to  open  externally,  the 
abscess  should  be  opened  by  an  incision  made  from  a  point  within 
the  mouth,  and,  after  sterilization  of  the  tract,  a  drainage  tent  of 
antiseptic  gauze  should  be  introduced  nearly  to  the  bottom  of  the 
pus  cavity.  This  should  be  removed  daily,  the  abscess  cavity  steril- 
ized, and  the  tent  renewed.  An  antiphlogistic  compress  should  be 
applied  to  the  face.  The  principal  object  sought  is  the  mechanical 
apposition  of  the  walls  of  the  abscess  cavity  at  the  dependent  or 


1  Dental  Brief,  1908;  Academy  of  Stomatology. 


534  PERICEMENTITIS 

external  portion,  in  order  that  these  shall  unite  by  granulation  and 
that  the  fistula  shall  in  this  manner  become  an  ordinary  one.  The 
patient  should  lie  in  a  position  to  counteract  the  natural  effect  of 
gravitation. 

After  lancing,  the  mouth  should  be  kept  well  sterilized  by  frequent 
sprays  or  gargles  of  hydrogen  dioxid,  which  may  be  diluted  to  one- 
third  strength  with  water — i.  e.,  to  a  1  per  cent,  solution. 

When  the  general  periosteum  is  involved,  as  shown  by  extensive 
boggy  swelling  in  the  mouth,  if  several  free  incisions  carried  to  the 
bone  do  not  afford  prompt  relief,  the  tooth  which  is  the  center  of 
infection  should  be  promptly  extracted.  If,  in  the  continued  course 
of  the  pericementitis,  chills,  followed  by  fever,  a  coated  tongue,  and 
much  physical  depression  occur,  a  general  infection  is  to  be  feared, 
and  no  time  should  be  lost  in  sterilizing  the  mouth,  extracting  the 
tooth,  and  subjecting  the  socket  to  free  spraying  with  antiseptics. 
Systemic  treatment  is  to  be  given  (see  pages  529  and  532). 

After-treatment.  —  The  after  treatment  of  acute  apical  abscess 
which  has  been  relieved  by  abortion  is  exactly  that  of  moist  gangrene 
or  of  chronic  abscess  without  fistula  (which  see).  In  very  mild 
cases  the  formaldehyd  treatment  may  be  instituted  at  once.  In 
severe  cases  it  is  better  to  allow  drainage  for  a  day  or  two.  When 
the  relief  has  been  afforded  by  lancing  the  treatment  is  as  for  chronic 
abscess  with  a  fistula  (see  page  541). 

One  may  not  expect  to  find  the  bone  immediately  restored  in 
either  case. 

Acute  septic  apical  pericementitis  may  occur  on  a  temporary  tooth, 
most  frequently  a  temporary  molar.  The  symptoms  and  pathology 
are  the  same,  except  that  the  looser  character  of  the  alveolar  struc- 
ture seems  to  frequently  permit  the  abscess  to  assume  the  chronic 
form  before  the  dentist  is  consulted.  Children  often  hide  these 
conditions  from  their  elders  out  of  fear  of  the  dentist.  In  strumous 
children  the  inflammation  may  be  spreading  and  the  lymphatic 
glands  may  be  involved.  There  may  also  be  some  symptoms  of 
septic  intoxication  evidenced  by  chills  accompanied  by  fever,  etc. 
These  cases  require  an  opening  of  the  abscess,  sterilization  of  the 
part,  and  attention  to  the  systemic  condition.  If  seen  in  the  acute 
stage  the  treatment  is  the  same  as  for  the  permanent  teeth,  unless 
the  disease  occur  shortly  before  the  date  for  eruption  of  the  per- 
manent successor,  when  the  temporary  tooth  should  be  extracted. 
If  treated,  the  canals  should  be  filled  with  materials  which  can  be 
resorbed  by  the  tissues,  such  as  paraffin  or  wax  with  aristol,  para- 
form,  or  thymol  (Fig.  547). 


CHAPTER  XVII. 
CHRONIC  SEPTIC  APICAL  PERICEMENTITIS. 

Strictly  this  title  refers  to  any  long-continued  septic  inflammation 
of  the  apical  tissue,  but  as  nearly  all  such  are  due  to  continued  infec- 
tion from  the  root  canals  we  have  the  following  varieties : 

1.  When  an  acute  abscess  is  aborted  via  the  root  canal  or  when 
open  roots  are  infected  and  cause  semi-acute  or  chronic  abscesses 
Avhich  find  some  vent  via  the  canal. 

This  is  known  as  chronic  apical  abscess  discharging  via  the  root 
canal  (which  in  reality  acts  as  a  fistulous  tract). 

2.  An  acute  apical  abscess  runs  its  active  coiu-se  and  discharges  in 
one  of  the  described  locations  (see  pages  518  to  523).  This  is  known 
a  chronic  apical  abscess  with  fistula. 

3.  An  abscess  sac  forms  upon  the  end  of  a  root  having  no  vent  or 
only  partial  vent  and  chronically  persists  without  other  discharge 
than  a  possible  absorption  of  the  pus  into  the  blood.  This  may  be 
of  various  grades  and  is  called  a  chronic  blind  apical  abscess. 

The  apical  granuloma  (4)  may  also  have  a  small  abscess  within  it. 

4.  The  tissues  react  slowly  to  the  infection  and  irritation,  form  a 
more  or  less  dense  granulation  tissue  which  in  its  enlargement  causes 
apical  bone  absorption.  This  growth  is  commonly  known  as  a  granu- 
loma. They  are  of  several  varieties  as  will  be  described  later  (p.  555). 
It  may  or  may  not  contain  pus  cavities  or  may  be  cystic  in  character. 

CHRONIC  APICAL  ABSCESS  DISCHARGING  VIA  THE 
ROOT  CANAL. 

Pathology  and  Morbid  Anatomy. — First  Grade. — Upon  abortion  of 
an  acute  abscess  in  the  first  stage  the  pressure  of  pus  upon  the  apical ' 
tissues  is  released,  and,  as  a  rule,  the  walls  of  the  abscess  cavity 
throw  out  granulations  which  fill  it.  This  tissue  tends  to  organize 
into  more  or  less  healthy  tissue  (cicatricial  tissue).  The  bacteria 
are  more  or  less  killed  out  except  at  that  part  represented  by  imme- 
diate contact  with  the  root  foramen;  at  this  point  the  tissues  are 
infected  and  some  molecular  loss  of  tissue  as  pus  may  occur.  A 
limited  loss  of  granulation  tissue  by  pus  formation  is  compensated  for 

( .535 ) 


536  CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 

by  the  formation  of  new  granulations.  The  conditions  are  ahnost 
analogous  to  those  existing  in  putrefaction  of  the  pulp,  and  require 
analogous  treatment. 

Second  Grade. — If  the  abortion  of  the  abscess  has  only  partly 
permitted  the  pus  to  drain,  or  the  alveolar  walls  or  crypts  of  the 
abscess  wall  remain  infected,  the  pus  will  continue  to  form  and 
escape  in  some  degree  via  the  canal.  If  the  tooth  now  be  extracted, 
a  small  abscess  sac  will  be  found  upon  the  root  end.  If  opened, 
this  will  be  seen  to  be  a  mass  of  fibrovascular  tissue  (inflamed  peri- 
cemental apical  tissue)  having  a  central  lumen  connecting  with  the 
root  canal  (the  abscess  cavity). 

The  so-called  chronic  blind  apical  abscess  (3)  does  not  differ  from 
this  pathologically  except  in  having  no  outlet  and  it  may  be  that  the 
second  and  third  grades  may  be  intimately  bound  up  with  the  granu- 
lomata. 

Thied  Grade. — With  partial  vent  to  the  pus  formed,  the  abscess 
cavity  of  the  second  grade  may  enlarge,  involve  the  bony  walls  of 
the  alveolus,  and  the  soft  tissues  then  pro- 
FiG.  509  liferate  to  such  an  extent  that  they  finally 

organize  into  a  large,  fibrous,  vascular  sac 
attached  to  the  tooth.  This  sac  has  the 
central  pus  cavity  before  described,  which  is 
connected  with  the  pulp  canal.  It  may  be 
a  half -inch  or  more  in  length  (Fig.  509), 
and  may  be  extracted  with  the  tooth  or 
may  be  left  attached  to  the  bone.  It  neces- 
sarily occupies  in  the  latter  a  cavity  of  a  size 
thi?d  Trad:r"i:  S:S2  corresponding  to  its  own  bulk.  As  its  inner 
sac  containing  a  central  walls  are  infected,  extraction  without  its 
rt;^S:^2;afton?alin1  removal  leaves  an  infected  area,  which  must 
pus.  be  disinfected  or  a  secondary  acute  abscess 

may  result.  (See  page  529.)  One  case  which 
had  given  only  slight  uneasiness  owing  to  partial  vent,  was  treated 
at  two  o'clock  and  the  tooth  extracted  at  midnight,  had  the  appear- 
ance shown  in  Fig.  509. 

Fourth  Grade. — Instead  of  organizing,  the  fibrovascular  tissue 
may  be  liquefied  into  pus  or  be  liquefied  after  organization  and  bone 
resorption.  The  root  apex  becomes  denuded  for  a  distance  about 
the  apical  foramen.  Pus  collects  about  the  apex  of  the  root  and  rests 
upon  the  bone,  owing  to  the  influence  of  gravity.  The  bone  is  thus 
infected,  inflamed,  and  further  liquefied,  while  necessarily  the  abscess 
cavity  enlarges.  If  a  bistoury  be  thrust  through  the  labial  alveolar 
wall  in  such  a  case,  as  sho"v\Ti  in  Fig.  510,  but  slight  resistance  will 


CHRONIC  APICAL  ABSCESS 


537 


need  to  be  overcome.     In  the  lower  jaw  the  tendency  is  to  burrow 
into  the  cancellated  tissue  of  the  bone  away  from  the  tooth,  so  that 


Fig.  510 


Fia. 


Chronic  abscess  on  upper  incisor,  showing 
tendency  of  pus  progressively  to  destroy  peri- 
cementum, owang  to  the  influence  of  gravity. 


Chronic  abscess  upon  lower  tooth 
showing  tendency  of  pus  to  sink 
into  the  substance  of  the  lower 
maxilla,  owing  to  the  influence  of 
gravity. 


destruction  of  the  pericementum  may  not  be  very  extensive.  In  the 
upper  jaw  the  tendency  is  to  spread  along  the  pericementum  and  into 
the  cancellated  bone,  so  that  the  cavities  of  chronic  abscess  upon 


Fig  512 


Fig.  513 


Chronic  apical  abscess  discharging 
through  the  hard  palate  and  threatening 
to  discharge  labially. 


Chronic  abscess,  showing  de- 
nudation of  apex  of  root  (a  to  h), 
with  deposits  of  calculi  (a)  upon 
cementum. 


the  upper  anterior  teeth  particularly  may  cause  extensive  excavation 
in  the  palatal  process  of  the  superior  maxillary  bone  (Fig.  512).    The 


538 


CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 


pus  may  burrow  in  irregular  and  circuitous  directions  until  it  finds 
external  vent. 

In  long-established  cases  deposits  of  pus  calculi  (serumal)  may 
form  upon  the  root  end  (Fig.  513).  The  cement  corpuscles  of  the 
apical  cementum  may  die  and  the  root  tissue  itself  become  infected. 
In  other  cases  resorption  of  the  root  end  occurs.     (See  Resorption.) 

Symptoms. — In  all  of  these  cases  the  formations  are  gradual,  owing 
to  the  partial  vent  or  accommodation,  and  no  pain  beyond  a  slight 
gnawing  or  feeling  of  fulness  or  an  occasional  reflex  pain  may  occur. 
If  for  any  reason  a  vent  become  occluded,  the  pus  formation  may 
become  rapid  and  an  acute  abscess  is  set  up,  which  may  be  painful 
or  not,  according  to  the  amount  of  tension  produced  before  discharge 
of  the  pus.  Aside  from  this,  the  gum  color  at  the  apex  is  somewhat 
deepened,  the  tooth  is  slightly  loosened,  and  slightly  tender  to 
percussion.    Signs  of  previous  moist  gangrene  are  in  evidence. 

Diagnosis. — The  passage,  without  production  of  sensation,  of  an 
undue  length  of  fine  probe  into  a  canal  is  evidence  of  destruction  of 
apical  tissue  and  a  guide  to  its  probable  extent. 

Fig.  514 


Central  abscessed.  Lateral  as  described  in  text,  p.  501.  Resorption  of  cuspid, 
looks  like  a  perforation  but  due  to  lingual  half  of  apical  end  being  eaten  out  by 
resorption.     All  teeth  extracted. 


A  radiograph  will  show  the  area  of  bone  destruction  caused  either 
by  suppuration  or  resorption.  This  area  may  be  largely  filled  with 
granulations  a  few  days  after  abscess  abortion  or  in  the  other  various 
chronic  abscesses  or  granulomata.  The  quantity  of  pus  discharged 
at  any  one  time  is  a  fair  guide  to  the  size  of  the  pus  cavity,  but  a  large 
bone  cavity  according  to  the  radiograph  may  be  lined  with  granu- 
lations or  possibly  it  may  be  necrosed.  In  a  few  cases  with  fair 
foramina  the  end  of  the  probe  may  produce  sensation  which  is 
fair  evidence  that  granulations  have  been  formed  and  that  living 
tissue  is  present.  Talbot  places  a  finger  of  the  left  hand  over  the 
suspected  apical  spaces  and  strikes  the  cusps  with  a  heavy  instru- 


CHRONIC  APICAL  ABSCESS  539 

meiit  at  different  angles,  vibration  of  the  left  finger  indicates  a 
space. ^ 

An  extensively  inflamed  gum  tissue  over  the  apex  indicates  a 
probable  approach  of  pus  formation  to  gum  tissue.  The  presence 
of  pus  in  the  canal  or  upon  several  dry  cottons  introduced  for  absorb- 
ent purposes  is  diagnostic  of  chronic  apical  abscess  e^'en  though  a 
granuloma  is  present 

If  the  probe  encounters  sensitive  living  tissue  in  the  probable 
region  of  the  apex  and  no  pus  can  be  found  while  yet  a  radiograph 
shows  an  area  of  apical  bone  destruction,  a  diagnosis  of  apical  granu- 
loma is  to  be  made.  However,  as  both  are  infective  conditions  if  a 
dressing  be  placed  which  shall  not  in  itself  be  powerful  enough  to 
destroy  the  apical  infection,  a  true  acute  apical  abscess  may  super- 
vene.    This,  therefore,  is  not  a  diagnostic  test  (Figs.  515  and  543). 

A  root  cyst  is  sometimes  diagnosable  at  once  by  its  presence  over  a 
root.  It  is  usually  bluish  about  its  margin  with  a  clear  stretched  look 
in  the  center.  It  cannot  be  diagnosed  as  such  by  radiography  but 
may  be  inferred  when  an  area  apparently  circumscribed  by  bone 
shows.     It  should  be  treated  surgically.     (See  Apicoectomy.) 

Treatment. — The  first  and  second  grades  of  chronic  apical  abscess 
discharging  via  the  canal  may  be  treated  upon  exactly  the  same 
principles  which  are  involved  in  the  treatment  of  moist  gangrene 
of  the  pulp.  The  infection  is  considered  as  simply  more  deep  seated, 
so  that  it  is  necessary  to  pass  disinfectants  into  the  abscess  cavity 
with  two  objects  in  view:  (1)  To  destroy  the  bacteria  present;  (2) 
to  stimulate  the  tissues  to  granulative  activity.  The  canal  should  be 
scraped  and  .the  foramen  very  slightly  enlarged  if  necessary  with  a 
fine  Donaldson  cleanser,  the  canal  having  been  flooded  with  10  per 
cent,  formalin  or  formocresol  as  an  antiseptic. 

If  necessary  the  root  canal  may  be  otherwise  enlarged.  (See 
page  497.) 

A  dressing  of  10  per  cent,  formalin  or  phenol-camphor  to  which  a 
little  menthol  and  a  drop  of  formaldehyd,  40  per  cent.,  have  been 
added,  or  modified  formocresol,  should  be  loosely  placed  in  the  canal 
and  the  tooth  sealed  for  twenty-four  hours  with  cement,  or,  if  the 
tooth  has  been  very  troublesome  and  is  still  tender,  temporary 
stopping  may  be  used  and  the  patient  provided  with  instriunents 
suited  to  the  removal  of  the  covering  and  the  cotton.  It  is  better 
that  the  tooth  should  be  under  the  control  of  the  patient.  At  the 
next  sitting  the  canal  dressings  are  more  tightly  made  unless  the  tooth 
is  still  sore  when  eugenol  plus  menthol  or  camphophenique  plus 
menthol  is  to  be  placed  in  the  canal — run  down  with  a  probe  and 

1  Dental  Cosmos,  1916,  p.  727. 


540 


CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 


formocresol  on  cotton  placed  in  the  pnlp  caAity.  The  seal  may  still  be 
temporary  stepping  if  mastication  has  not  pro\ed  destructive  of  the 
pre^'ious  one.  This  is  simply  one  method  of  treatment,  other  methods 
are  to  be  found  on  page  493.  When  no  pus  can  be  found  on  the  dress- 
ing or  following  it,  or  on  an  exploratory  cotton  twist,  and  there  is  no 
odor  or  pain,  and  if  a  culture  proves  negative  (see  page  503)  the  root 
may  be  filled;  a  temporary  crown  filling  of  gutta-percha  should  be 
used  for  a  week  or  two.  Each  change  of  dressing  should  be  done 
under  aseptic  precautions  (see  p.  448). 

In  a  relatively  few  cases  teeth  cannot  be  closed  at  all  without  a 
recurrence  of  trouble  within  a  short  period,  which  trouble  is  usually 
relieved  by  opening  the  tooth.  The  repetition  of  this  is  annoying, 
and  in  some  cases  is  due  to  the  strength  of  medicaments  such  as 
formaldehyd,  which  should  be  modified  or  abandoned  for  sedative 
antiseptics  such  as  phenol-camphor   or   eugenol    plus    menthol    or 


Fig.   515 


Fig.   516 


Abscess  on  tooth  infected  from  mouth 
(see  text.) 


The  same  as  Fig.  515  (see  text). 


an  aqueous  rnedicament  plus  iodoform  (see  page  500).'  In  some  of 
the  cases  the  gases  may  accumulate  more  rapidly  than  disinfec- 
tion occurs.  In  other  cases  the  irritability  of  the  tissues  seems  to 
produce  intolerance  of  any  remedial  measures.  What  is  known 
as  "systematic  stopping  and  unstopping"  seems  sometimes  to  over- 
come the  irritability  and  accustom  the  tissues  to  being  covered. 
The  system  consists  of  stopping  with  the  appropriate  germicide  for 
about  eight  hours,  or  from  morning  to  afternoon,  then  venting  and 
redressing  until  the  following  morning,  then  for  twenty-four  hours, 
then  forty-eight,  then  seventy-two,  etc.,  until  the  tooth  stays  stopped, 
or  in  some  cases  the  redressing  may  be  done  for  several  days  con- 
secutively. Thus  in  one  recent  troublesome  case  three  daily  dressings 
of  formocresol  in  the  pulp  chamber,  then  a  Howe  treatment  with 
formocresol  over  it,  followed  by  a  similar  treatment  after  forty-eight 
hours  and  a  third  after  another  forty-eight  hours  started  the  tooth 
on  a  comfortable  progress.     In  the  case  shown  in  Figs.  515  and  516 


CHRONIC  APICAL  ABSCESS  WITH  FISTULA  541 

the  crown  was  but  a  shell  with  caries  even  within  the  root.  A  com- 
bination of  amalgam  and  cement  plus  thjTiiol  was  placed  on' er  a  cotton 
pellet  in  the  root  and  before  final  hardening  the  filling  was  drilled 
through  and  the  cotton  removed.  Formaldehyde  was  tried  but 
pain  ensued.  It  was  treated  with  an  aqueous  solution  and  iodoform 
and  finally  filled.    Pus  was  present  for  some  time,  later  it  disappeared. 

There  have  been  a  few  patients  who  cannot  seem  to  have  teeth 
"treated,"  nearly  all  cases  being  practical  failures  even  when  aseptic 
Some  few  may  be  kept  in  comfort  for  a  while  with  permanent  vents, 
but  this  is  objectionable,  both  from  the  oral  sepsis  and  chronic  apical 
abscess  standpoint.  In  all  troublesome  cases  persistently  collecting 
pus  at  the  apices  and  in  all  third  and  fourth  grade  cases,  and  trouble- 
some granulomata  etc.,  an  artificial  fistula  should  be  established  and 
the  case  conducted  accordingly.  This  is  better  and  saves  time.  In 
some  cases  apicoectomy  should  be  instituted  at  once  after  canal 
disinfection,  instead  of  this  intermediate  treatment. 

In  no  case  should  hydrogen  dioxid  be  forced  in  quantity  into  the 
pus  occupying  such  an  abscess  cavity  until  the  fistula  has  been  made, 
and  it  is  better  even  then  to  avoid  it.  It  may  bring  about  great  pain, 
owing  to  the  rapid  reaction  of  the  hydrogen  dioxid  with  the  pus  and 
blood  present.  In  some  cases  hydrogen  dioxid  has  forced  pus  into 
remote  locations  without  destroying  it.  As  an  adjuvant  to  abort 
acute  suppurations  of  all  sorts,  ]Medalia^  suggests  the  use  of  stock 
vaccines  made  of  some  40  or  50  strains  of  Staphylococcus  aureus 
and  pneumococcus  in  the  general  average  of  150  millions  of  former 
to  50  or  75  millions  of  the  latter  to  the  dose.  (See  Vaccines  in 
Pyorrhoea.) 

Autogenous  vaccines  are  used  for  the  more  persistent  cases,  the 
bacteria,  of  course,  obtained  from  the  pus  of  the  abscess. 

CHRONIC  APICAL  ABSCESS  WITH  FISTULA. 

Morbid  Anatomy  and  Pathology. — This  form  of  chronic  abscess 
occurs  as  the  result  of  the  discharge  of  an  acute  abscess  through  the 
gum  or  other  part  of  the  surface  of  the  body,  and  whether  the  fistula 
has  naturally  occurred  or  been  artificially  established.  (The  interior 
of  the  mouth  or  other  cavity  exposed  to  contact  with  the  air  is 
considered  external  to  the  body  proper.) 

If  the  acute  abscess  has  been  severe  or  long  continued,  the  tissue 
destruction  may  be  great,  but,  as  a  rule,  granulation  promptly  sets 
in  and  the  walls  of  the  abscess  cavity  organize  into  cicatricial  tissue. 
From  the  interior  of  this  a  canal  (fistula  or  sinus)  lined  with  cica- 

.    I  Dental  Cosmog,  January,  1914. 


542 


CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 


Fig.  517 


tricial  tissue  leads  to  the  surface,  the  pus  being  almost  constantly 
formed  at  the  expense  of  the  granulation  tissue,  which  is  as  constantly 
renewed. 

The  fistulous  opening,  as  a  rule,  appears  as  a  small  teat  of  inflamed 
and  sometimes  pedunculated  tissue  located,  in  the  majority  of  cases, 
upon  the  buccal  surface  of  the  gum,  about  a  quarter  of  an  inch  below 
the  apex  of  the  root  and  slightly  distal  to  it — a  position  probably 
determined  by  the  density  of  the  tissues  surrounding  the  acute  abscess. 

At  times  the  only  evidence  of  a  fis- 
tula is  a  small  spot  of  inflammation 
surrounding  a  minute  opening,  from 
which  pus  exudes.  The  fistula  is 
sometimes  located  upon  the  lingual 
surface  of  the  gum.  It  may  per- 
forate the  bone  of  the  hard  palate 
and  open  through  the  mucous  mem- 
brane of  the  roof  of  the  mouth  (Fig. 
512).  Instead  of  finding  exit  by  a 
direct  path  through  the  buccal  or 
lingual  alveolar  plate  and  gum,  the 
pus  may  burrow  along  the  length  of 
the  pericementum  and  discharge 
at  the  neck  of  the  tooth,  and  sim- 
ulate a  pyorrhea  pocket  (Figs.  497 
and  498).  One-half  or  more  of  the 
lateral  aspect  of  the  pericementum 
may  remain  vital,  although  involved 
in  a  chronic  inflammation,  the  re- 
mainder being  destroyed.  Not  in- 
frequently the  pus  burrows  along 
the  surface  of  the  bone  and  dis- 
charges at  a  point  over  an  eden- 
tulous portion  of  the  jaw.  This  is 
common  to  a  lower  bicuspid.  It 
may  burrow  in  the  direction  of 
the  apices  of  other  teeth,  destroy  their  pulps  and  thus  cause  an 
abscess,  having  added  causes  for  persistence.  (See  Acute  Abscess, 
Class  5,  p.  514.) 

When  the  apices  of  the  roots  of  upper  posterior  teeth  lie  in  very 
close  proximity  to  the  floor  of  the  antrum,  perforation  of  this  floor 
may  occur  before  tissue  destruction  has  proceeded  far  enough  in 
other  directions  to  afford  escape  to  the  pus  (Fig.  501).  Extensive 
pus  accumulations  may  occur  in  the  antrum  in  consequence^  and 


Chronic  alveolar  abscess  of  the  root 
of  a  lower  incisor,  with  abscess  cavity 
passing  through  the  body  of  the  bone 
and  discharging  on  the  skin  beneath 
the  chin:  a,  very  large  abscess  cavity; 
b,  mouth  of  the  fistula.     (Black.) 


CHRONIC  APICAL  ABSCESS  WITH  FISTULA 


543 


when  the  tissues  in  the  antral  floor  are  afi^ected,  other  teeth  may  be 
involved.  It  may  discharge  into  the  nasal  cavity,  as  a  result  of  an 
acute  abscess;  at  such  points  the  discharge  may  remain  persistent. 
Sometimes  the  discharge  occurs  through  the  canal  of  the  affected 
tooth;  the  canal  then  acts  as  a  fistula  (Fig.  493).     Upon  a  lower 


Fig.  518 


Fig.  519 


Fistula  passing  down  through  the  body  of 
the  lower  maxilla.     (Black.) 

tooth,  particularly  the  incisors,  the 
pus  may  burrow  downward  through 
the  cancellated  tissue  of  the  bone 
and  emerge  at  the  base  of  the  bone 
and  open  upon  the  face  (Fig.  .518). 

In  other  cases  the  pus  may  per- 
forate the  bone  and  find  passage 
along  the  submuscular  tissue,  open- 
ing upon  the  face  or  neck  (Fig. 
519).  The  apices  of  the  roots  of 
teeth  lying  beneath  the  line  of  in- 
sertion of  the  mylohyoid  muscle 
may  cause    an    abscess    to   open    in 

the  neck  cavity.  Cryer  records  a  case  where  an  abscess  opening 
upon  the  face  immediately  anterior  to  the  line  of  the  facial  artery 
was  traced  to  the  root  of  a  lower  molar;  the  direction  of  the  sinus 
is  shown  in  Fig.  520.  In  a  case  having  a  similar  anatomical  associa- 
tion the  pus  penetrated  the  bone  lingually,  was  encapsuled  beneath 
the  internal  pterygoid  muscle,  and  appeared  as  a  swelling  at  the 
inner  aspect  of  the  angle  of  the  jaw.  Another  case  dissected  along 
the  muscles  of  the  neck  and  discharged  at  the  clavicle.  Occasionally 
the  apices  of  the  roots  of  lower  molars  are  separated  from  the  inferior 
dental  canal  by  only  a  thin  lamina  of  bone,  so  that  discharge  into 
this  canal  may  occur  with  infiltration  along  the  vessels  and  nerves 


Chronic  alveolar  abscess  at  the 
root  of  a  lower  incisor,  with  a 
fistula  discharging  on  the  face  under 
the  chin:  a,  abscess  cavity  in  the 
bone;  b,  b,  b,  fistula  following  in 
the  periosteum  down  to  the  lower 
margin  of  the  body  of  the  bone  and 
discharging  on  the  skin.   (Black.) 


544  CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 

in  the  canal.  Discharge  into  the  nasal  chamber  is  most  frequently 
associated  with  abscess  upon  the  upper  incisors. 

Cementum  infection  occurs  as  a  sequence  to  death  of  the  cement 
corpuscles  from  lack  of.  nutrition.  Pus  calculi  may  also  form  on  the 
roots  in  the  long  continued  cases.  The  granulation  tissue  springing 
up  about  the  parts  has  a  resorbent  action  and  the  root  ends  are 
often  resorbed,  though  this  action  is  probably  to  an  extent  counter- 
acted by  the  alkalinity  of  the  pus.  The  formation  of  the  latter  may 
however  be  in  abeyance  at  times.  In  certain  areas  h}^ercementosis 
may  occur.  A  comprehension  of  these  effects  may  be  best  obtained 
by  the  consideration  of  granulomata  which  to  the  mind  of  the  writer 
represents  that  form  of  living  resistant  tissue  which  in  its  active  form 
is  capable  of  hj'percemental  construction  or  resorption  and  in  its 
degenerative  form  produces  cysts,  abscess,  etc.  (see  Fig.  539). 

The  extent  of  tissue  destruction  varies  considerably,  but  is  usually 
greatest  in  dependent  parts,  gravity  influencing  the  burrowing  of 
the  pus. 

Symptoms  and  Diagnosis. — A  fistula  is  seen  upon  the  gum,  visible 
as  either  a  small  teat  of  flesh  (perhaps  pedunculated),  discharging 
pus,  or  as  a  tiny  orifice  in  the  gum  surrounded  by  inflamed  tissue, 
and  from  which  pus  may  be  squeezed  (Fig.  500).  As  a  rule,  a  soft 
silver  probe  may  be  passed  to  the  apex  of  a  nearby  root,  whether 
possessing  a  crown  or  embedded  in  the  bone  (Fig.  307) .  In  case  of  an 
external  opening  upon  the  face  a  similar  procedure  shows  the  trouble 
to  lie  with  some  tooth  root.  The  .r-rays  will  often  be  valuable  in 
determining  the  exact  location  of  the  abscess  cavity,  but  as  a  rule  a 
fistulous  tract  does  not  show  well  in  a  radiograph. 

Upon  the  teeth  themselves  but  four  conditions  may  cause  a  fist- 
lous  opening:  (1)  Putrefaction  of  the  pulp  or  its  equivalent  apical 
infection;  sometimes  the  sinus  is  at  the  oral  end  of  a.  broken  root; 
(2)  septic  perforations,  apical  or  lateral;  (3)  a  pericemental  abscess 
(see  Pericemental  Abscess) ;  or  a  secondary  abscess  associated  with 
a  pyorrhea  pocket  (see  Pyorrhea  Alveolaris);  (4)  lateral  abscess 
about  a  third  molar  or  impacted  tooth. 

Aside  from  these,  the  probe  may  lead  to  carious  or  necrosed  bone, 
a  cyst,  or  a  subperiosteal  abscess  (maxillary  periostitis). 

In  these  cases  the  probe  does  not  lead  to  a  root.  Carious  bone 
will  impart  a  honey-combed  sensation  to  an  excavator;  necrosed 
bone  will  be  exposeS  and  firm,  or  the  sequestrum  will  be  in  evidence 
as  a  movable  body.  There  may  also  be  several  fistulse  and  extensive 
inflammation  of  the  tissue.  A  cyst  will  be  a  tumor  with  certain 
characteristics  (see  page  187),  and  an  impacted  tooth  will  usually  im- 
part the  feel  of  smooth  enamel  to  the  instrument,  though  the  enamel 


CHRONIC  APICAL  ABSCESS  WITH  FISTULA 


545 


may  at  times  be  rough  at  certain  points.  An  embedded  root  will  be 
movable,  and  will  present  the  dentin  and  its  central  opening,  the  pulp 
canal,  as  diagnostic  features.  It  may  require  radiography  for  deter- 
mination. ]\Iaxillary  periostitis  will,  as  a  rule,  have  a  history  of 
traumatism,  or  the  previous  use  of  a  probably  infected  h^'podermic 
needle  associated  with  it.     In  all  cases  not  clearlv  due  to  other  than 


Fig.  520 


Fig.  521 


Abscess  with  tortuous  sinus,  open- 
ing upon  the  face:  A,  tissue  of  cheek; 
B,  floor  of  mouth;  C,  abscess  tract. 

Fig.  522 


Large  abscess  cavitj'  in  relation  with  a 
lateral  incisor,  complicated  by  an  im- 
pacted supernumerary  tooth  beneath  the 
nasal  spine.  (Philadelphia  Dental  College 
Museum.) 


dental  causes,  evidence  of  the  four 
dental  conditions  mentioned  should 
be  sought. 

A    cln-onic    abscess    with    fistula 

occasionally  heals  at  the  orifice  and 

may  break  out  again.    This  shows 

a   spontaneous   return   to    a   blind 

abscess.    For  this  reason  in  any  case  of  apparent  cure  by  root  filling, 

etc.,  a  radiograph  should  be  taken  at  varying  periods  to  determine  a 

real  cure. 

Treatment. — Necrosed,  or  carious  bone,  abscesses  or  perforations 
and  pericemental  abscesses  will  be  treated  of  under  proper  headings. 
Here  only  chronic  apical  abscess  with  fistula  will  be  discussed. 

In  the  cases  due  to  moist  gangrene  of  the  pulp  the  canals  must  be 
35 


Abscess   and   resorption   at   apex. 
(Radiograph  by  Lodge.) 


546  CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 

freely  entered,  the  apical  foramen  opened  with  Donaldson  or  other 
cleansers,  and  the  canals  and  abscess  tract  thoroughly  sterilized. 

Owing  to  the  complexities  of  most  roots  the  following  procedm^e 
seems  necessary.  The  pulp  cavity  and  coronal  portion  of  canals  are 
prepared  for  easy  entrance  and  the  apical  portions  gently  syringed 
out  while  agitated  with  a  fine  broach.  As  the  case  is  one  of  pulp 
putrefaction,  no  unnecessary  force  should  be  used. 

The  canals  are  now  dried  and  a  formocresol  dressing  introduced 
into  the  pulp  cavity  only  and  tightly  sealed  with  cement  or  temporary 
stopping.     (See  pages  495  and  498.) 

A  radiograph  is  made  before  dismissal  which  is  developed  before  the 
next  sitting  or  the  patient  is  referred  to  a  radiographer  for  the  same. 

With  this  as  a  guide,  the  non-fistulous  root  is  treated  as  for  simple 
putrefactive  pulp  (it  being  possible  to  excite  an  abscess  on  it) ,  but  the 
fistulous  root  is  made  continuous  with  the  abscess  tract.  Formocresol 
or  phenolsulphonic  acid^  or  10  per  cent,  aqueous  formaldehyd  may 
be  in  the  canal  while  working  upon  it.  A  thread  of  cotton  with  strong 
phenol  is  to  be  packed  in  the  fistulous  canal  and  pressure  with  raw 
vulcanite  or  gutta-percha  made  on  this  cotton  only  to  force  the 
phenol  through  the  fistula,  which  may  be  prevented  from  burning  the 
mouth  by  holding  a  bit  of  cottonoid  roll  over  the  fistula.  The  escharo- 
tic  effect  is  valuable.  Hydrogen  dioxid,  or  antiseptic  liquid  soap  or 
Talbot's  iodoglycerol  may  be  used  if  preferred.  Phenolsulphonic 
acid  may  be  used. 

The  non-fistulous  canals  are  to  be  treated  with  formaldehyde 
dressings  on  cotton  gently  placed.  These  dressings  are  renewed  with 
formocresol  until  sterility  is  certain  (see  page  503)  and  the  abscess 
healed. 

The  nozzle  of  a  hypodermic  needle  may  be  fitted  to  the  canal  by 
packing  wax,  temporary  stopping,  or  raw  vulcanite  about  it;  a  piece 
of  flexible  tubing  may  be  previous!}'  stretched  over  the  free  end 
and  the  other  end  of  the  tubing  stripped  over  the  compressed-air 
syringe.  Medicaments  or  air  may  thus  be  blown  through  the  fistula. 
Instead  an  abscess  syringe,  filled  with  an  antiseptic,  may  be  used  in 
like  manner.  The  method  should  be  cautiously  used  in  fistulous 
cases  only,  except  for  reasons  well  known  by  the  operators  employing 
them,  as  very  painful  distention  of  the  cheek  may  occur.    (See  p.  504.) 

The  rubber  cup  shown  in  Fig.  526  may  be  used  as  a  vacuum  pump 

'  Phenolsulphonic  acid  consists  of  97  parts,  by  weight,  of  concentrated  sulphuric 
acid  and  93  parts,  by  weight,  of  phenol,  kept  at  100°  C.  for  about  twenty-four  hours 
to  produce  a  reaction,  when  sufficient  distilled  water  is  added  to  make  the  liquid 
assay  about  80  per  cent,  of  phenolsulphonic  acid.  (Buckley,  Lilly.)  Prinz,  in  Cosmos, 
April,  1912,  gives  some  good  reasons  for  its  inferiority  for  any  purpose  to  sulphuric 
acid,  though  Buckley  has  gho-syn  good  results  from  its  usg  in  chronic  apical  infections. 


CHRONIC  APICAL  ABSCESS  WITH  FISTULA 
Fig.  523  Fig.  524 

Q 


547 


1 


Minim  syringe. 


J.  N.  Farrar's  alveolar  abscess  syringe. 


Fig.  525 


Bulb  sjTinge.     (Berlin.) 


548 


CHROXIC  SEPTIC  APICAL  PERICEMENTITIS 


to  draw  the  pus  from  the  fistula  or  to  draw  medicaments  through 
the  canals.  If  modified  by  introducing  a  glass  tube  and  connecting 
this  up  with  a  rubber  bulb  the  saliva  ejector  tube,  an  aspirator  pump, 
or  with  the  intake  of  an  air  compressing  pump  a  vacuum  device  of  any 
force  desired  may  be  obtained.  As  a  rule,  the  first  method  will  work 
if  any  of  them  will,  and  saves  time. 

Opening  the  fistula  daily  with  a  probe  or  needle  or  a  piece  of  iron 
stovepipe  wire  aids  healing  from  the  bottom  out.  This  may  be  done 
by  the  patient. 

Tissues  about  abscesses  have  an  inherent  tendency  to  repair;  cases 
of  long  standing  frequently  healing  promptly,  sometimes,  though  not 
often,  in  twenty-four  hours. ^ 


Fig.  52r 


Fig.  527 


Rubber  cup  to  be  used  as 

vacuum  cup. 


Amputation  of  root  apex:  OG.  opening  in 
the  gum  made  by  packing  fistula;  AC, 
abscess  cavity;  RF,  root  filling. 


In  indolent  chronic  inflammation  the  use  of  a  small  gum  dry 
cup  with  vacuum  bulb  attached  may  be  used  for  a  few  minutes 
at  a  time  several  times  a  day,  to  draw  fresh  blood  and  effusions 
into  the  inflamed  part.  The  opsonic  index  of  the  lymph  drawn 
in  is  said  to  be  raised  to  several  times  beyond  that  of  the  body  lymph, 
thus  rapidly  increasing  phagocytosis  in  the  part.  The  rubber  cup 
shown  in  Fig.  526  may  be  left  imperforate  and  furnished  the  patient 
for  this  purpose. 

If  the  abscess  cavity  does  not  heal  in  a  week  or  two  one  of  several 
causes  may  be  assigned:  (1)  The  cr\'pts  in  the  walls  of  the  abscess 
cavity  may  require  further  disinfection.  If  improving,  the  treatments 
are  continued  or  the  phenol,  etc.,  forcing  be  repeated,  or  the  Howe 
treatment  applied.    (2)  The  cotton  in  the  canal  may  have  absorbed 


'  Darby,  Proceedings  of  Academy  of  Stomatology,  Philadelphia,  1S99. 


CHRONIC  APICAL  ABSCESS  WITH  FISTULA 


549 


pus  formed  after  an  interval  of  antiseptic  influence  and  may  keep 
up  the  infection.  This  calls  for  a  non-absorbent  dressing  or  imme- 
diate root  filling,  after  say,  an  hour  of  formocresol  application  or  the 
Howe  treatment.  (3)  The  root  canal  may  not  be  explorable,  in 
which  case  the  Howe  silver  nitrate  method  may  be  employed  at  once 
on  finding  such  condition.  Apicoectomy  may  finally  be  required,  or, 
if  feasible,  performed  early.  (See  Apicoectomy.)  (4)  The  root  end 
may  be  encrusted  with  calculus,  or  the  cementum  be  infected,  or  dead 
bone  may  be  present. 


Fig.  528 


Fig.  529 


Fig.  530 


A  skiagraph  of  apical 
abscess  cavity  about  two 
root  apices;  incurable 
by  ordinary  means. 


The  same  after  root 
amputation. 


The  same  thirty 
days  later,  sho-n-ing 
a  certain  amount  of 
new  bone  formation. 
(Price.) 


For  these  cases  the  apical  foramen  should  be  sealed  and  the  abscess 
tract  sATinged  once  a  week  with  25  per  cent,  sulphuric  acid;  the 
mouth  and  clothing  being  properly  protected  by  using  a  pad  of  cot- 
tonoid  over  the  fistula  and  needle  to  absorb  the  excess.  This  dissolves 
calculi  and  disinfects  dead  cementum.  It  also  stimulates  the  soft 
parts  to  a  gi'anulative  action.  If  necessary  the  patient  should  receive 
appropriate  systemic  treatment,  especially  if  anemic.  (See  page  558.) 
In  this  way  some  old  and  somewhat  obstinate  cases  may  be  induced 
to  heal.  In  some  cases  gravity  so  retains  pus  in  abscess  cavities  that 
granulation  is  interfered  with.  The  instruction  of  the  patient  in  the 
s^Tinging  out  of  the  tract  with  a  mild  antiseptic  several  times  a  day 
is  of  great  value  in  that  it  removes  pus  which  if  retained  would  destroy 
granulations.  Hydrogen  dioxid  should  not  be  used  except  in  small 
abscesses  as  it  may  cause  the  forcing  of  pus  to  distant  areas.  ^lany 
apparently  desperate  cases  heal  of  their  own  accord  after  some  months. 
Some  success  attends  the  packing  of  a  root  with  a  thick  paste  of 
iodoform  after  opening  the  root  as  far  as  possible  (see  p.  476). 
Cases  in  which  a  canal  was  not  explorable  for  any  considerable  dis- 


550  CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 

tance  liave  healed  after  this  treatment.  The  .r-ray  apphcation,  made 
for  ten  or  twenty  seconds,  or  skiagraphy  seems  to  aid  the  heahng  of 
the  fistula.  The  high  frequency  current  also  is  a  stimulant.  A  metal 
probe  is  introduced  into  the  fistula  and  the  violet-ray  electrode  held 
in  contact  with  it.  If  the  abscess  be  incurable  by  the  above  methods 
or  radical  measures  being  considered  better,  without  attempting  con- 
servative measures,  the  root  end  may  be  amputated,  after  a  tight 
canal  filling  is  placed  beyond  the  point  at  which  amputation  is  to  be 
done.  From  the  standpoint  of  the  possible  eventual  incurability  or 
apparent  cure  with  a  pathological  condition  still  possible,  it  is  a 
saving  of  time  to  go  at  once  to  apicoectomy  root  amputation 
or  replantation.  The*  methods  are  discussed  in  special  chapters  in 
this  work. 

Necrosed  root  ends  may  occasionally  be  seen  projecting  through 
the  gum  and  alveolar  process  which  have  been  lost  above  them. 
They  should  be  removed  as  above  indicated.  Sometimes  salivary 
calculus  deposits  on  them. 

Perforations. — A  septic  perforation  may  occur  in  the  course  of 
opening  septic  root  canals.  As  a  rule,  the  canal  being  difficult  at 
first,  it  cannot  be  opened  after  perforation  because  the  probe  con- 
tinually follows  the  false  opening.  If  it  can  be  done  by  better  care, 
aided  by  radiography,  the  perforation  is  usually  near  the  crown  and 
can  sometimes  be  filled  with  gutta-percha  and  eliminated. 

In  a  few  cases  under  local  anesthesia  one  may  cut  down  through 
the  gum  upon  the  perforation,  pack  the  tissue  once  or  twice  with 
cotton  and  sandarac  plus  orthoform  and  cut  out  the  perforation  into 
a  cavity  and  fill  with  amalgam.  Again  packing,  the  amalgam  is 
smoothed  the  following  day.  A  probe  should  be  put  into  the  canal 
while  filling  to  maintain  the  canal  liunen.  Perforations  well  up 
toward  the  apex  call  for  apicoectomy  or  replantation  (which 
see)  or  extraction  as  they  cannot  be  filled  without  leaving  septic 
root  ends. 

Several  cases  of  fistulous  openings  into  the  antrum  have  been 
noted  by  canal  exploration  in  which  no  history  of  discomfort  from 
antral  empyema  could  be  obtained.  It  was  assumed  that  the  root 
ends  approximated  the  floor  of  the  antrum,  and  that  the  abscesses 
were  of  simple  chronic  type.  Such  cases  were  treated  upon  the 
common  principle  of  canal  antisepsis,  flushing  the  abscess  tract 
with  an  antiseptic,  and  filling  the  canals.  The  antral  condition 
was  explained  to  the  patients,  who  were  warned  of  possibilities,  but 
such  as  yet  have  not  been  reported. 

A  chronic  abscess  may  discharge  into  the  maxillary  sinus  for  a 
long  period  before  being  discovered,  unless  the  pus  accumulation  be 


CHRONIC  APICAL  ABSCESS  WITH  FISTULA  551 

extensive,  when  it  escapes  from  the  antrum  into  the  cavity  of  the 
nose,  discharging  by  one  side.  Smaller  accumulations  of  pus  find 
exit  in  the  recumbent  position,  and  attention  is  called  to  one  antrum 
as  the  seat  of  affection  by  noting  that  in  the  morning  pus  or  an 
offensive  secretion  appears  at  but  one  nostril.  The  patient  complains 
of  fulness  upon  lying  on  the  affected  side  and  is  relieved  by  lying  on 
the  opposite  side.  The  surgeon  may  note  it  upon  examination  or 
upon  suction  at  the  ostium  maxillse  (Brown).  Brown  notes  pain 
over  the  side  of  the  face  even  extending  to  the  frontal,  temporal  and 
occipital  regions,  tenderness  on  pressure,  hyperesthetic  skin,  neuralgia 
and  tic  douloureux;  in  rare  cases  bulging  of  the  buccal  antral  wall 
with  yielding  and  crepitation  on  pressure,  thinning  and  bulging  of 
the  palatal  wall  in  chronic  cases.  The  discharges  from  purulent 
nasal  catarrh  appear  upon  both  sides. 

High  transillumination  of  the  tissues  about  the  mouth  and  through 
the  cheek,  by  means  of  the  electric  mouth  lamp  of  20  volts  capacity, 
the  patient  being  in  a  dark  room  or  both  operator  and  patient  under 
a  spreading  dark  cloth,  may  reveal  an  opacity  on  one  or  perhaps  both 
sides,  indicating  the  presence  of  fluid  in  the  antrum.  A  clear  pinkish 
transillumination  is  a  sign  of  health.  Tumors  in  the  antrum  entirely 
obstruct  the  light.  Examination  of  the  posterior  teeth  will  show  one 
of  them  to  be  pulpless,  if  the  cause  lie  in  apical  abscess.  If  such  a 
tooth  be  extracted,  a  profuse  flow  of  pus  may  follow,  and  a  probe  may 
be  passed  through  an  alveolus  directly  into  the  antrum. 

The  diagnosis  may  be  assisted  by  .T-rays,  both  antra  being  radio- 
graphed for  comparison.  Raper^  states  that  the  shadow  does  not 
actually  demonstrate  the  presence  of  pus,  but  that  something  abnor- 
mal exists  whether  pus  or  a  soft  tumorous  growth,  the  appearance 
being  the  same.  It,  however,  locates  the  disease,  whether  in  the 
antrum  or  other  sinuses.  The  presence  of  opaque  foreign  bodies, 
as  a  piece  of  tooth  root  causing  disease,  is  shown  by  radio- 
graphy. 

The  teeth  should  be  radiographed  for  abscess,  etc.;  when  due  to  a 
tooth  extraction  is  the  best  sm'gical  relief. 

The  nozzle  of  an  atomizer  or  syringe,  filled  with  a  mild  antiseptic 
solution,  is  passed  into  the  antrum  and  the  cavity  is  freely  sprayed. 
A  probe  or  the  finger  is  passed  into  the  cavity  and  an  exploration 
made  to  detect  the  presence  of  any  dead  bone  or  bony  septi,  which, 
if  found,  must  be  removed,  the  cavity  of  entrance  being  enlarged 
to  permit  their  removal.  The  antrum  is  then  packed  with  gauze 
impregnated  with  iodoform,  etc.     After  a  few  days  the  cavity  is 

1  Items  of  Interest,  July,  1912. 


552 


CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 


sprayed  about  every  other  day  Avith  warm  Dobell's  solution,  \ery 
dilute  iodoglycerol,  Lugol's  solution,  or  sterile  ocean  water. 

In  one  case  in  which  the  writer  opened  into  the  antrum  while 
curetting  an  alveolus  necrotic  from  pyorrhea,  a  wide  opening  was  made 
for  exploration  in  the  morning,  and  a  small  vulcanite  plate  with  a 

Fig.  531 


A,  antrum  with  pus  in  it.    B,  healthy  antrum.    (Radiograph  by  Carmen  of  St.  Louis.) 
Courtesy  of  Dr.  Howard  R.  Raper. 

solid  upright  plug  constructed  and  inserted  in  the  afternoon.  The 
firm  clot  found  was  indented  by  the  plug,  but  did  not  dissolve.  The 
plug  was  cut  doMii  gradually  and  the  part  healed  by  organization  of 
the  original  clot.  The  antrum  was  not  diseased.  This  shows  the 
inherent  tendency  to  heal. 


CHRONIC  APICAL  ABSCESS  WITH  FISTULA 


553 


Fig.  532 


In  any  case  of  antral  enii)yema  cine  to  apical  abscess,  the  tooth 
may  be  extracted,  the  socket  enlarged  freely  as  abo^■e,  and  otherwise 
the  case  treatedj^in  the  same  manner  or  a  drainage  tnbe  teirporarily 
substitnted  for  the  ping.     It  might 
be  converted  into  a  ping  to  be  cnt 
down    later.       Other    methods    of 
treating    antral    empyema  are  em- 
ployed.    (See   works    on   Oral   Sur- 
gery.) 

Unless  necrosis  of  bone  occur, 
cases  of  fistula  opening  upon  the 
face  or  neck  may  be  healed  by  the 
ordinary  methods  of  canal  treat- 
ment, carried  out  with  extraordi- 
nary care  to  accomplish  the  irriga- 
tion of  the  fistula,  or  at  least  steri- 
lize the  apical  tissue.  The  scar 
formation  is  less  than  when  extrac- 
tion is  practised  for  the  removal  of  the  cause.  If  the  fistula  be 
indolent,  the  granulations  may  be  stimulated  by  means  of  an 
injection   of    10    per  cent,    silver   nitrate    solution.     If   the  fistula 


Emypema     of     antrum      due     tc 

abscess  upon  root  of  bicuspid  tooth. 
(Radiograph  by  Price.) 


Fig.  533 


Fig.  534 


Sear  caused  by  alveolar  abscess  dis- 
charging on  the  face.     (Black.) 


Operation  for  the  remedy  of  scar  on  the  face 
caused  by  alveolar  abscess.      (Black.) 


obstinately  refuse  to  heal,  the  tooth  should  be  extracted  and  necrosed 
bone,  if  any  be  present,  surgically  removed,  though  apicoectom}'  may 
be  tried. 


554  CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 

Flagg^  suggested,  as  a  means  of  lessening  scar  formation,  that  a 
seton  be  passed  through  the  external  fistula  into  the  mouth,  and  that 
it  be  gradually  drawn  into  the  mouth  as  the  external  fistula  heals, 
after  which  the  tooth  is  to  be  extracted  if  otherwise  incurable. 

In  fistulse  discharging  upon  the  face  the  formation  of  scar  tissue 
may  bind  the  tissue  of  the  cheek  tight  to  the  bone.  When  this 
occurs  beneath  the  tip  of  the  chin,  the  scar,  after  healing,  usually 
resembles  a  dimple,  and  calls  for  no  interference.  The  scar  and 
binding  down  along  the  border  of  the  inferior  maxilla,  or  beneath 
the  malar  bone  in  the  upper  maxilla,  may  produce  deformity  calling 
for  remedy  (Figs.  533  and  534).  Black's  operation  is  to  be  performed 
to  lessen  the  deformity,  for  its  complete  correction  is  not  practicable. 
A  finger  placed  in  the  mouth  draws  the  cheek  away  from  the  alveolar 
wall,  when  the  exact  position  of  the  cord  of  attachment  is  discovered. 
A  tenotome  knife  is  passed  into  the  tissues,  dividing  the  band  of 
attachment;  a  long  pin  is  passed  through  the  most  depressed  portion 
of  the  scar,  its  center,  the  long  ends  of  the  pin  resting  upon  the 
face;  strips  of  adhesive  plaster  laid  upon  the  skin  under  the  head 
and  point  of  the  pin  will  prevent  the  latter  sinking  into  the  soft 
tissues.  The  pin  is  retained  for  several  days,  until  the  cut  in  the 
mouth  heals.  The  principle  involved  is  the  supplying  of  a  new 
section  of  scar  tissue  which,  while  it  shrinks,  makes  the  total  length 
ofjthe  cord  greater,  hence  less  binding. 

Systemic  Complications. — The  cachectic,  debilitated,  anemic,  tuber- 
culous, and  syphilitic  are  liable  to  extensive  pus  formation,  which 
enlarges  the  cavity  unduly  and  may  involve  the  roots  of  other 
teeth  or  even  cause  devitalization  of  their  pulps,  which  aids  in  the 
continuance  of  the  abscess  by  adding  a  fresh  cause. 

In  such  cases  all  the  dead  pulps  should  be  removed  after  careful 
diagnosis,  and  the  patient  should  be  instructed  in  the  use  of  a  Sub. 
Q.  or  Berlin  syringe  and  a  mild  antiseptic,  the  object  being  to  keep 
the  dependent  parts  free  of  pus  and  allow  granulations  to  form  rather 
than  be  constantly  broken  down.  In  such  cases  hydrogen  dioxid 
should  be  avoided  as  it  may  force  undestroyed  bacteria  into  remote 
parts. 

In  addition,  such  systemic  medication  or  remedial  measures  as 
will  raise  the  recuperative  and  resistant  powers  of  the  tissues  should 
be  employed.  The  application  of  these  is  to  be  conducted  by  a  con- 
sultant physician. 

If  very  persistent,  a  vaccine  may  be  employed,  after  the  method 
of  Wright,  to  raise  the  opsonic  index  or  Medalia's  method  of  using 

'  Lectures  on  Dental  Therapeutics. 


CHRONIC  BLIND  APICAL  ABSCESS  565 

stock  vaccines  of  known  source  may  be  employed  (see  index). 
The  direct  results  of  infection,  toxemic  and  septicemic,  have  already 
been  considered.  Grieves  contends  that  man}'  root  ends  remain 
necrotic  and  develop  blind  abscesses  and  their  sequela?  (which  see). 

Chronic  Blind  Apical  Abscess. — A  true  blind  abscess  is  one  with- 
out a  point  of  discharge.  It  is  a  result  of  septic  contamination 
from  root  canals,  a  condition  in  which  bacteria  in  unfilled  root 
apices  or  in  the  interspaces  between  a  root  filling  and  the  canal 
wall  find  their  way  into  the  fluid  entering  such  a  space  and  produce 
putrefaction — a  condition  practically  analogous  to  moist  gangrene 
of  the  pulp;  or  else  bacteria  in  the  blood  arising  from  some  other 
source,  dental,  tonsillar,  or  other  focus,  or  entering  to  form  a  general 
blood  infection,  enter  an  apical  region  previously  weakened  as  by 
pulp  removal,  apical  irritation  by  root  canal  filling,  a  previous  abscess, 
etc.,  and  develop  a  chronic  apical  abscess. 

An  apical  abscess  is  formed  and  the  apical  tissue  acts  as  a  fibro- 
vascular  envelope  or  sac.  Under  the  pus  pressure  and  the  pumping 
force  of  masticatory  movement,  absorption  of  toxins  and  pus  germs 
by  way  of  the  lymphatics  occurs.  The  lymphatic  glands  may  be 
involved;  a  systemic  infection  occurs.  It  is  differentiated  from 
granuloma  by  a  discharge  of  pus  on  opening  the  root  apex.  It  is 
treated  as  is  an  abscess  discharging  via  the  canal.     (See  p.  535.) 

Granuloma. — Under  conditions  of  low  grade  irritation  by  the  gases, 
toxic  substances  and  bacteria  of  low  virulence  in  root  canals,  contain- 
ing dead  pulp,  imperfect  root  fillings,  etc.,  the  apical  tissue  develops 
into  a  more  or  less  solid  mass  of  soft  tissue.  This  mass  of  tissue  is 
larger  than  the  original  apical  space,  as  a  rule,  hence  it  represents  an 
enlargement  of  apical  tissue  and  must  and  does  lie  in  an  enlarged 
space  in  the  bone  corresponding  to  the  size  of  the  granuloma.  Though 
its  enlargement  may  remove  the  overlying  bone  this  is  due  to  bone 
resorption.  Examination  of  these  growths  have  shown  that  a  pus 
cavity  is  only  found  in  the  later  stages  of  comparatively  few  and  these 
then  may  be  the  source  of  chronic  blind  apical  abscess  if  continued, 
or,  if  they  suddenly  become  active  may  institute  acute  apical  abscess 
or  subacute  apical  abscess,  meaning  by  the  latter  that  form  of  abscess 
which  causes  cold  abscess  or  a  fistula  without  production  of  pain 
such  as  occurs  in  acute  apical  abscess,  as  a  rule,  or  may  produce 
occasional  irritations  which  subside. 

Pathohistology. — The  more  recent  and  accessible  work  on  this 
subject  has  been  done  by  Thoma,^  Hartzell  and  Henrici-,  Dewey ,^ 

1  Jour.  Nat.  Dent.  Assn.,  October,  1917. 

2  Dental  Cosnaos,  January,  1918. 
.  3  Ibid.,  July,  1918. 


556  CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 

Eisen  and  I^  y,^  -  and  Endelman,^  who,  hoAvever,  claim  no  originality 
and  who  are  mentioned,  to  exclusion  of  others,  simply  for  the  A'alue 
of  their  demonstrative  work  and  easy  accessibility.  These  writers 
are  agreed  that  the  growth  consists  of  an  exterior  fibrous  capsule 
continuous  at  the  sides  of  the  root  apex  with  the  pericementum  (and 
probably  consists  of  the  proliferated  pericemental  fibers. — Ed.)  and 
it  extends  into  the  trabeculse  of  bone.  Its  interior  or  central  portion 
consists  of  delicate  connective  tissue  filled  with  plasma  cells  (cells 
oval  in  form,  with  single  excentrically  situated  nucleus,  the  cyto- 
plasm taking  basic  stain  and  regarded  by  Hartzell  and  Henrici  as 
characteristic  of  chronic  inflammation)  and  containing  bloodvessels. 

Touching  this  histology  and  the  name,  the  following  definition  of 
a  granuloma  is  taken  from  Hertzler's  "Treatise  on  Tumors,"  a  work 
not  related  to  dentistry:  "A  tumorous  enlargement  and  a  structural 
resemblance  to  the  newly  formed  tissue  of  wound  healing."  The  term 
is  applied  by  Hertzler  to  giunma  and  other  infectious  growths  of 
chronic  inflammatory  character  and  seems  fairly  applicable  to  the 
dental  condition.  So  far  what  is  termed  a  "simple  granuloma"  has 
been  described.  Certain  degenerative  changes  may  occur  in  the 
central  tissue. 

The  stimulation  may  cause  a  proliferation  of  the  natural  epithelial 
cells  of  the  part  (variously  called  epithelial  root  sheath  of  Hertwig, 
epithelial  debris  of  jNIalassez,  glands  of  Black,  or  remains  of  enamel 
organ),  "producing  an  epithelial  mass  which  breaks  down  in  the 
center,  it  is  believed,  by  fatty  degeneration  and  a  space  is  formed 
containing  a  fluid."  This  produces  an  epithelium-lined  cavity,  known 
as  a  paradental  or  peri-apical  cyst  (Fig.  541).  The  fluid  may  contain 
cholesterin  crystals,  which  may  in  some  cases  appear  in  quantity 
(Fig.  541).  The  fatty  degenerated  tissue  may  be  thickened  into  a 
pultaceous  mass,  known  as  caseation,  and  if  a  pus  cavity  is  formed 
is  the  chronic  blind  abscess  described  on  page  555. 

Calculus  has  been  found  in  the  center  of  the  granuloma,  probably 
due  to  fatty  degeneration.-^  Certain  effects  of  chronic  inflammation 
are  noted,  i.  e.,  root  resorption  and  hj'percementosis,  which  are 
regarded  by  the  writer  as  effects  of  such  chronic  non-septic  inflamma- 
tion or  hyperemia  as  may  be  present  (even  though  the  central  cause 
is  infective).  Necrosis  of  the  osteoblasts  in  the  cementum  producing 
a  necrotic  root  end  is  the  natural  result  of  any  loss  of  attachment  or 
infection  reaching  them.  This  is  held  by  many  as  rendeiing  the 
pericementum  incapable  of  normal  reattachment  and  as  indicating 
necessity  for  apicoectomy  when  possible. 

1  Dental  Items  of  Interest,  February,  1-916  -  Ibid.,  p.  88. 

2  Dental  Cosmos,  November,  1917.  ■■  Hartzell  and  Henrici. 


GRANULOMA   ABSCESS 


557 


Bacteriology. — Hartzell  and  Henrici  usually  found  the  root  cysts 
and  granulomas  infected,  and  regard  the  Streptococcus  viridans  as 
the  cause  of  the  non-suppurative  lesion  and  state  that  when  pus  is 
present  the  staphylococci,  especially  the  S.  albus  is  present.^ 


Fig.   535 


Fig.   5.36 


Acute   abscess,   not   shown  in  radio- 
graph.    Two-rooted  second  bicuspid. 


Apical  infections.    Case   of   arthritis 
much  improved  after  extraction. 


Endelman  has  shown  that  when  these  sacs  (or  chronic  abscess) 
were  implanted  in  culture  media  without  disturbing  them,  no  growth 
occurred  in  several  instances,  while  their  contents  produced  abundant 
growth.  This  would  seem  to  show  a  tendency  to  circumvallation 
and  resistance  to  infection,  w^hich  may,  however,  be  broken  down. 
This  fact,  taken  with  extension  of  inflammatory  elements  outside  the 
capsule,  show  the  bone  to  be  probably  aseptically  absorbed  (Fig.  542). 


Fig.  537 


Fig.  538 


Case  of  septic  pericementitis.  Root 
hollowed  out  and  perforated  by  caries. 
Fungous  gum  in  root. 


Granulomas  on  bicuspid  and  both 
roots  of  first  molar. 


Systemic  Complications.- — There  is  still  work  to  be  done  to  settle 
the  question  as  to  how  far  granuloma  and  chronic  blind  abscess  may 
be  considered  dangerous.  It  is  claimed  by  Rosenow  and  others  that 
these  are  the  most  frequent  cause  of  arthritis,  endocarditis,  muscular 
rheumatism,  distant  abscesses,  etc.,  though  any  other  foci  of  infection 


1  Hartzell  and  Henrici,  p.  1067. 


558 


CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 


such  as  in  pyorrhea  pockets,  the  tonsils,  nasal  sinuses,  appendix 
vermiformis,  etc.,  may  also  act  to  produce  these  conditions.  The 
follow'ing  possibilities  of  effects  are  grouped  by  Grieves  i^ 


Fig.  539 


M 

K^i.^^K^^^^ 

i 

■  'w^^ 

i 

i1 

m 

Root  with  granuloma,  showing  resorption  of  root ;  pulp  necrosed.     Inflammatory- 
granulation  tissue.     (Thoma.) 

Fig.  540 


Photomicrograph  of  cross-section  of  granuloma  removed  by  apicoectomy.     Note  epi- 
thelial lining  in  the  center  of  the  lesion.     (Thoma.) 

1.  Upon  the  muscles,  causing  myositis. 

2.  Upon  the  joints,  causing  arthritis,  synovitis,  etc. 

3.  Upon  the  blood,   causing  septic  and  pernicious  anemia  and 
endocarditis  or  pleurisy. 

4.  Upon  the  glands,  causing  lymphadenitis. 


J  Dental  Cosmos,  May,  1914,  p.  568. 


GRANULOMA 


559 


5.  Upon  the  nervous  system,  causing  toxic  neuritis  and  degenera- 
tion. 

6.  Upon  the  organs  of  excretion,  causing  skin  rashes  and  nephritis. 

7.  Upon  the  gastro-intestinal  tract,  causing  septic  gastritis,  enter- 
itis, cholecystitis,  appendicitis,  cohtis,  etc.,  and  their  sequelae. 

In  the  kidney  lesions,  Hartzell  notes  albuminuria  and  casts  in 
quantity,  lessening  as  the  local  foci  of  pus  formations  are  removed.^ 

The  symptom-complex^  is  mainly  an  anemic,  pasty  complexion, 
malaise,  loss  of  appetite,  debility,  night  sweats,  loss  of  weight,  low 
fever  (100°),  or  subnormal  temperature. 

Fig.  541 


Granuloma  with  capsule;  epithelial  proliferation, lining  cystic  ca^-ity  cholesterin  crystals. 

(Thoma.) 


The  abscesses  are  within  the  bone  of  the  Jaw  while  the  dental 
s\Tnptoms  may  not  be  noticeable  though  the  tooth  may  be  slightly 
tender  and  there  may  be  tenderness  upon  pressure  over  the  apical 
region.  There  may  be  pain  about  the  eyes  or  in  the  back  of  the  head 
or  neck.  The  postcervical  glands  may  be  enlarged.  The  fact 
that  teeth  have  apparently  been  attended  to  is  no  warrant  that 
septic  conditions  are  not  present,  these  conditions  embracing  any 
form  of  gingivitis  or  of  pericemental  infection,  including  pyorrhea. 

'  Journal  of  Allied  Societies,  June,  1914. 
2. Dental  Cgsinog,  May.  1914,  p.  569. 


560  CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 

Experiments  by  Hartzell  in  animals  in  an  endeavor  to  produce  sys- 
temic lesions,  such  as  abscess  of  the  kidney,  were  successful,  but  the 
chief  evidence  adduced  of  connection  between  apical  granulomata  and 
systemic  disease  is  the  frequent  recovery  of  patients  after  the  granu- 
lomas were  removed,  though  when  the  extra-oral  disease  is  well 
implanted,  there  is  no  absolute  reason  why  it  should  not  continue  the 
infection  on  its  own  account  and  require  other  methods  of  treatment. 
Not  infrequently  cases  of  granuloma  are  complicated  by  the  presence 
of  pyorrhea  alveolaris,  or  other  conditions  of  sepsis,  such  as  filthy 
bridges,  abundant  calculus,  etc.,  and  there  is  still  left  the  task  of 
grouping  the  spnptoms  accompanying  each  class  of  cause. 

A  Fig.  542 


Section  shomng  that  the  capsule  does  not  always  mark  the  boundaries  of  the  abscess. 
Chronic  dento-alveolar  abscesses  are  frequently  trabeciilated,  two  or  more  compart- 
ments entering  into  the  formation  of  one  so-called  abscess  sac.  A,  Fibrous  capsule; 
B,  Inflammatory  elements  which  make  up  bulk  of  abscess;  C,  Inflammatory  tissue 
reaction  outside  capsule.     (Endelman.) 

In  the  main  pyorrheal  conditions  and  abscess  with  sinus  are  first 
apt  to  disturb  the  digestive  tract,  causing  indigestion,  intestinal 
putrefaction,  toxemia  and  their  malnutritional  sequelae,  while  blind 
abscess  and  granuloma  are  more  likely  to  produce  the  conditions  due  to 
direct  trans?nission  of  infection  via  the  blood  stream  (see  the  classifica- 
tion by  Grieves,  page  558) .  Pyorrhea,  etc.,  if  permitting  absorption  of 
bacteria  at  the  pocket  might  produce  the  sa7iie  conditions  as  the  granu- 
lomas.   ]\Iany  persons  seem  absolutely  well  in  spite  of  the  presence  of 


GRANULOMA  561 

peri-apical  infection,  this  being  considered  due  to  systemic  resistance 
liable  to  break  down  when  most  required  during  some  period  of 
greater  stress  as  an  illness  from  some  other  cause,  overwork,  etc. 

The  granuloma,  etc.,  being  in  vascular  relations  and  being  always 
infected,  the  infection  may  be  transferred  to  the  blood  and  the 
bacteria  locate  wheresoever  they  will  and  in  the  new  location 
produce  the  subacute,  non-purulent  inflammatory  conditions  known 
as  myositis,  arthritis,  etc.  Rosenow  concludes  from  experiments  that 
these  bacteria  have  selective  affinity  for  parts  to  which  they  are 
accustomed.  Thus  in  many  cases,  those  taken  from  an  appendix 
have  selective  affinity  for  the  appendix  of  the  experimental  animal. 

In  this  connection,  in  a  lecture,  Price^  demonstrated  a  case  of  severe 
^\Ty-neck,  due  to  a  diseased  tooth.  A  piece  of  cervical  muscle  contained 
the  same  bacteria  as  the  dental  region  and  the  ground  muscle  injected 
into  rabbits  produced  characteristic  wry-neck  in  them. 

It  is  considered  that  the  non-pyogenic  streptococci  are  the  main 
bacteria  concerned.  The  toxins  having  affinity  for  cells  also  produce 
disease  and  symptoms. 

Diagnosis. — Every  discolored  or  sore  tooth  should  be  suspected  and 
radiographed  unless  test  shows  it  thoroughly  vital  (see  p.  483).  The 
presence  of  a  defined  dark  area  in  the  negative  {film)  at  the  apex, 
together  with  no  root  filling  or  apparently  imperfect  filling  is  war- 
rant for  opening  the  root  canal  and  establishing  a  connection  between 
canal  and  granuloma.  If  pus  flows  it  is  a  case  of  chronic  abscess,  if 
none,  it  is  considered  granuloma. 

Treatment. — Upon  finding  the  pulp  dead  or  upon  removing  a  partial 
root  filling,  the  writer  prefers  to  ignore  the  dift'erential  diagnosis, 
places  formocresol  for  twenty-four  hours  and  proceeds  as  in  cases  of 
pulp  putrefaction  (see  p.  493).  This  is  done  because  of  the  danger 
of  acute  abscess  being  set  up  by  exploration  at  the  first  sitting. 
This  form  of  treatment  is  best  in  cases  of  granuloma  uncomplicated 
b}^  systemic  conditions.  In  case  such  are  noted  no  matter  how  mild, 
and  nearly  every  patient  will  complain  of  something,  a  neuritis, 
mild  attacks  of  rheumatism,  indigestion,  bilious  attacks,  headaches, 
neuralgia,  nervousness,  debility,  a  previous  breakdown,  etc.,  both 
granuloma,  etc.,  and  gingival  disorders  should  be  looked  for,  the 
probable  relation  explained  and  thorough  treatment  advised.  This 
is  a  matter  of  conscience  with  the  dentists  as  the  patient  will  have 
no  knowledge,  as  a  rule,  of  the  relation.  In  severe  systemic  disorders 
either  the  teeth  and  mouth  may  be  considered  first,  but  often  is  the 
last  examined  area  because  other  possibilities  are  excluded. 

1  Lecture  before  the  Pennsjdvania  State  and  other  Societies,  1917. 

36 


562 


CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 


Radiography  of  the  entire  denture  or  at  least  of  suspected  areas 
picked  out  by  a  discriminating  dentist  should  be  done.  In  severe 
systemic  complications  extraction  or  root  amputation  is  imperative 
for  the  reason  that  other  methods  are  less  certain  of  eradicating  the 
focal  infection.    Naturally  extraction  is  preferred  in  posterior  teeth. 

In  either  case  the  granuloma  should  be  removed  and  the  bone 
curetted  and  a  clot  allowed  to  form,  as  a  rule  (see  Apicoectomy) . 
The  reason  for  rapid  eradication  is  that  treatment  via  canal  is  depen- 
dent upon  the  recuperation  of  the  tissues  and  requhes  considerable 
time,  three  months  to  a  year,  to  demonstrate  a  cure  and  the  need  of 
the  patient  is  imperative. 


Fig.  543 


Fig.  544 


Same     case     as    Fig.     544.     Pus  Same  case  as  Fig.  543.     Centrals 

equalled    cavity  in  volume.     Right  extracted.    Bridge  with    open-faced 

central  has  root  end  resorbed  into  a  crowns  on  laterals.    Shows  complete 

cup  which   held    pus.     Unfortunate  healing,  though  no  curettement  was 

canal    filling.     Left   central  chronic  done.     Note  bone  septum  in  center, 

abscess  with  fistula.  Right  lateral 
seems  involved  but  was  vital.  Posi- 
tion of  teeth  reversed  in  radiograph. 

HartzelP  states  that  "An  arthritis  once  started  by  tonsillitis  or 
similar  large  foci  can  be  kept  going  by  an  oral  infection  so  slight  as 
to  be  scarcely  recognizable  in  the  radiograph  and  systemic  diseases 
are  continued  by  surprisingly  shallow  gingivitis  even  when  the  larger 
local  foci,  doubtless  the  originators  of  the  trouble  are  removed." 

Greeves,^  in  a  late  article,  condemns  all  treatment  of  root  canals 
having  infections  of  the  apex  associated  unless  apicoectomy  is  a  part 
of  the  program,  claiming  too  great  danger  of  continued  apical  infec- 
tion. He  also  condemns  opening  and  attempting  to  refill  cases  show- 
ing partial  root  filling  to  the  middle  third  when  no  granuloma  is 
evident,  claiming  that  a  virulent  reinfection  arises.  This  may  be  due 
to  his  non-use  of  formocresol  without  an  adequate  substitute  (see 
Arguments  on  page  495) .    In  severe  systemic  disease  one  or  more  apices 


1  Jour,  of  Nat.  Dent.  Assn.,  November  15,  p.  339. 

2  Ibid.,  August,  1918,  p.  789, 


BONE  COMPLICATIONS 


563 


Fig.  545 


of  roots  may  be  saved  for  the  purpose  of  making  an  autogenous  vac- 
cine from  the  diseased  tissue.  This  should  be  done  and  injected 
for  a  period  at  suitable  intervals  by  a  skilled  laboratory  physician. 

This  is  to  raise  the  opsonic  index  against  the  bacteria  in  the  joints, 
etc.  While  the  writer  has  had  no  experience  "^dth  the  method  it  would 
seem  that  Wright's  treatment  with  succinimide  of  mercury  injections 
would  be  indicated  in  desperate  cases  not  recovering  by  the  former 
methods  of  treatment.  It  has  been  claimed  that  apical  abscesses 
"dry  up"  with  this  treatment.  If  so,  joints,  etc.,  should  be  reached. 
(See  Treatment  of  Pyorrhoea.) 

Granting  that  the  root  canal  may  be  a  proper  avenue  of  treatment, 
the  root  canal  is  later  mechanically  opened,  as  shown  on  pages  448 
and  539,  with  care  to  penetrate  the  granuloma  or  abscess  with 
broaches.  The  treatment  of  the  granulomatous  tissue  consists  in  its 
sterilization,  if  possible,  or  stimulation  to  increased  phagoc;^i;osis  and 
granulation.  This  being  diseased  tissue  there  can  be  no  harm  in 
passing  phenolsulphonic  acid,  80  per  cent.,  into  the  sac  with  this 
object  in  view.  Nor  can  the  writer  believe 
that  formocresol  dressings  in  canals  are  in- 
jurious, provided  antisepsis  be  attained. 
Ionization  may  be  used  (see  page  496).  In 
brief  the  treatment  is  as  for  pulp  putrefac- 
tion (see  page  493). 

Bone  Complications. — In  any  case  of  apical 
abscess  necrosis  or  caries  of  bone  may  occur  or 
the  root  end  alone  may  become  necrotic.  A 
portion  of  necrotic  bone  may  be  sequestered 
and  exfoliated  or  operative  interference  may 
be  necessary.  In  carious  bone  the  osteoporo- 
sis and  ulceration  may  be  progressive  and  in- 
volve much  bone.  Apicoectomy  and  the  re- 
moval of  any  dead  bone  is  the  indication  in 
simpler  cases  and  extraction  and  bone  re- 
moval in  the  more  severe.  The  present  demands  of  oral  hygiene 
do  not  admit  of  partial  measures.  (See  Apicoectomy.)  The  same 
is  true  if  sj^Dhilis,  scarlet  fever,  typhoid  or  mercury  has  caused  the 
necrosis.  The  illustration  (Fig.  546)  shows  a  case  of  necrosis  with 
two  external  sinuses  along  the  lower  border  of  the  mandible  associated 
with  great  pain  or  recumbency,  rise  and  fall  of  temperature  and 
occurrence  of  stupor  and  coma.  The  operation  consisted  of  extrac- 
tion of  the  cuspid  and  first  bicuspid,  removal  of  the  sequestrum, 
curettement  of  bone  and  drainage.^ 


Blind  abscess  which 
developed  acute  symp- 
toms. Cured  by  extrac- 
tion of  aU  three  teeth. 


1  Practice  of  Dr.  Gilmer,  description  by  Dr.  Howard  R.  Raper,  Dental  Items  of 
Interest,  July,  1912. 


564 


CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 


Necrotic  alveolar  walls  may  result  in  advanced  pyorrhea.  It  may 
also  occur  from  the  bruising  of  the  periosteal  lining  of  the  alveolus  as 
the  result  of  extraction  of  a  hypercementosed  root,  or  from  a  bruise 
induced  by  forcible  use  of  forceps  in  the  removal  of  deeply  seated 
roots.  Possibly  it  may  also  occur  from  infection  by  apical 
abscess,  etc.,  after  extraction. 

Fig.  546 


The  white  line  is  artificial  and  shows  the  extent  of  the  sequestrum  (see  text). 
(Radiograph  bj'  Raper.) 


The  clot  seems  to  fail  at  times  after  extraction  with  anesthe- 
tics containing  adrenalin  or  suprarenin.  In  some  cases  the  socket 
may  be  free  of  blood  for  several  minutes  after  extraction.  Ragged 
gum  margins  may  become  gangrenous,  although  sometimes  not. 
After  extraction  any  loose  margin  of  gum  or  rough  edges  of  process 
should  be  trimmed  up. 

The  walls  of  the  alveolus  become  infected  by  pyogenic  organisms. 

The  leaving  of  cotton  tampons,  placed  as  vehicles  for  pain-relieving 
agents,  for  an  undue  length  of  time  also  invites  infection. 

The  gum  margins  are  perhaps  sloughing;  the  bone  may  be 
exposed  and  exquisitely  painful  to  touch,  or  it  may  be  necrotic  and 
insensitive  superficially.     The  case  is  one  termed  "dry  socket." 

Cases  of  general  septicemic  or  pyemic  infection  from  this  source 
have  been  recorded. 


BONE  COMPLICATIONS 


565 


In  the  majority  of  cases  the  pain  is  of  a  deep,  boring,  continuous 
character.  Reflex  pains  are  also  produced  about  the  face.  Much 
debihty  is  caused  by  the  wearing  character  of  the  pain,  the  loss  of 
sleep  and  appetite,  and  probably  also  because  of  absorption  of 
toxins. 

Treatment. — The  mouth  and,  in  so  far  as  possible,  the  inflamed 
part  must  be  sterilized.  Probably  mercuric  chlorid  in  hydrogen 
dioxid  (1  to  1000)  will  answer  best.  If  the  solution  be  used  hot, 
whether  it  be  merciu-ialized  or  not,  the  pain  is  much  relieved.  Talbot's 
iodoglycerol,  one-fourth  to  full  strength,  is  valuable  and  penetrating. 

Under  mucous  or  conductive  anesthesia  all  sloughing  gum  should 
be  cut  away,  and  acutely  inflamed  or  necrotic  bone  should  be 
cut  away  with  large  sterile  burs  until  healthy  tissue  is  reached. 
After  washing  out  the  debris  and  further  sterilization  a  clot  is  to 
be  induced  by  curetting  if  necessary.  The  mouth  is  to  be  kept 
sterilized  and  the  patient  is  to  be  seen  daily  for  a  repetition  of  the 
curetting  if  the  clot  fail,  or  the  alveolus  may  be  genth'  packed  with 
cotton  saturated  with  balsam  of  Peru  alone  or  with  castor  oil,  equal 
parts,  as  a  stimulant.  Trichloracetic  acid  in  saturated  solution,  or 
silver  nitrate,  or  aromatic  sulphuric  acid  may  be  used  as  a  special 
stimulant  and  the  balsam  packing  renewed.  In  ordinary  cases  one 
or   two   local   treatments  will  be 

effective,  but  the  tonic,  antiseptic,  f^g-  ^47 

systemic  medication  recommended 
under  the  heading  of  acute  apical 
abscess  is  advised. 

An  alternative  proceeding  may 
be  adopted.  A  pellet  of  cotton  wet 
with  campho-phenique  should  be 
rolled  in  powdered  orthoform  and 
introduced  into  the  socket  after 
sterilization  with  iodine,  or  a  stiff 
mass  made  from  orthoform,  zinc 
oxid,  and  vaselin  may  be  packed 
into  the  alveolus  as  an  antiseptic 

and  anesthetic.  The  repetition  of  this  after  five  to  eight  hours  will 
afford  marked  relief.  (Jack.\)  Later  the  radical  operation  may  be 
performed  if  granulation  does  not  set  in.  While  alveoli  will  fill  with 
granulations  in  the  absence  of  a  clot  filling  them,  such  a  clot  seems 
to  be  the  best  protection  against  sepsis  and  a  depressed  scar  tissue. 
In  some  of  these  cases  portions  of  bone  may  exfoliate.  In  one  obsti- 
nate case  the  capsule  of  bone  surrounding  the  apex  of  the  alveolus 
came  away. 

*  International  Dental  Journal,  1905. 


Showing  the  relations  of  an  abscess 
upon  a  temporary  tooth,  with  the  crown 
of  a  developing  permanent  tooth  under- 
lying it. 


566 


CHRONIC  SEPTIC  APICAL  PERICEMENTITIS 


Chronic  Septic  Pericementitis  in  the  Temporary  Teeth. — Any  of  the 
chronic  septic  conditions  described  may  occur  upon  the  temporary 


Fig.  548 


Fig.  549 


i;     .1  '!i; 


\,  •     •yi 


\  ■■:•... "5.  '/    ,x-/ 


Dentin  from  the  root  of  an  abscessed 
tooth,  showing  the  penetration  of  cocci  to 
a  depth  of  about  xV  mm.  (23^0  i^-)  '<  ^^e 
side  a  to  &  bordered  upon  the  canal. 
X  1000.     (Miller.) 


teeth.  The  presence  of  resorption 
and  of  the  permanent  crown 
usually  confines  the  inflammation 
to  a  point  lower  in  the  alveolar 
process  than  in  the  case  of  perma- 
nent teeth.  The  loose  character  of 
the  structure  causes  the  ulcera- 
tion to  occupy  a  larger  area,  and 
the  parts  in  chronic  inflammation 
look  more  angry,  but  are  fairly 
well  tolerated.  The  treatment  is 
practically  the  same  for  the  curable 
cases;  the  others  should  be  ex- 
tracted. The  root  canals  when 
treated  should  be  filled  with  absorb- 
able materials,  such  as  paraflfin  or 
wax  combined  with  aristol.  Buckley 
recommends,  as  a  canal  filling  in  these  cases,  the  use  of  a  stiff 
mixture  of  calcium  phosphate  and  formocresol  (formalin,    1  part; 


Sector  of  a  cross-section  from  a  dis- 
eased root:  a,  cementum;  b,  stratum 
granulosum;  c,  very  narrow  and  finely 
branched  tubules;  d,  penetration  of 
bacteria  into  tubules.  X  150. 
(Miller.) 


CHRONIC  APICAL  ABSCESS  567 

cresol,  1  or  2  parts),  to  be  packed  into  the  pulp  chamber  and  zinc 
phosphate  quickly  flowed  over  it;  the  cavity  to  be  filled  later. 

Johnson^  suggests  that  a  eucalyptol  solution  of  gutta-percha  (see  p. 
479)  be  pumped  into  the  canals  and  pressure  exerted  with  temporary 
stopping  until  the  solution  appears  at  the  fistula.  The  temporary 
stopping  that  does  not  interfere  with  filling  integrity  should  be  left. 

Septic  Pericementitis  at  Bifurcations  of  Multi-rooted  Teeth. — 
Teeth  weakened  by  caries  may  fracture  after  filling  in  such  a  manner 
that  the  line  of  fracture  exposes  the  pericementum  at  the  bifurcation. 
The  crack  admits  septic  saliva,  and  a  filling  or  fillings  usually  sink 
gingivally,  wedging  apart  the  two  sections  and  admitting  more 
or  less  food  matter.  If  the  canals  of  the  sections  have  been  pre- 
viously treated  and  filled,  it  is  usual  to  find  a  more  or  less  general 
pericementitis  due  to  the  wedging  and  septic  irritation.  It  is  an 
open  question  if  such  teeth  can  be  saved  so  as  to  be  hygienic  and 
their  extraction  is  advised,  though  occasionally  one  root  may  be 
utilized  if  it  can  be  treated. 

Chronic  Septic  Apical  Pericementitis  (Non-purulent). — Continued 
apical  inflammation  of  a  low  grade  probably  is  a  condition  analogous 
to  apical  granuloma  or  the  infection  leading  thereto.  It  may  not 
show  in  a  radiograph. 

Miller^  has  shown  that  root  tubules  are  infected  only  for  a  short 
distance  at  their  canal  ends,  so  that  infection  from  the  perice- 
mentum via  the  cernentum  and  dentinal  tubules  is  highly  improb- 
able (Fig.  548) .  The  putrefaction  produces  gases,  and  these  exuding 
slowly  produce  the  irritation.  If  pyogenic  organisms  be  present,  apical 
abscess  may  at  any  time  supervene,  but,  as  shown  in  foregoing 
pages,  subacute  conditions  may  occur. 

Mayrhofer^  has  shown  that  even  formocresol  fails  to  sterilize  all 
tubuli,  so  that  bacteria,  especially  streptococci,  grow  back  into  the 
canal.  Price  and  Brooks^  demonstrated  the  great  difliculty  of  steril- 
izing all  parts  of  the  root  tubules  with  any  germicide.  If  the  canal 
filling  be  imperfect,  and  it  is  said  that  all  are,  it  is  obvious  that  apical 
infection  may  arise.  These  cases  are  puzzling.  Can  they  initiate 
sufficient  infection  to  cause  systemic  disease  without  a  granuloma 
appearing  in  a  radiograph?  If  so,  then  all  canal  filling  stands  con- 
demned as  m  the  presence  of  such  a  possibility  even  apparent  success 
may  mean  nothing  but  doubt  and  worry  and  the  so-called  "100  per 
cent,  vitality"  the  only  aim  worth  while.  The  only  hope  lies  in  the 
sufficient  application  of  germicide  of  known  germicidal  power  and 
tight  root  canal  filling.  Whether  we  shall  really  attain  this  end 
remains  to  be  seen. 

1  Dental  Cosmos,  1899.  « Ibid.,  1899. 

3  Items  of  Interest,  March,  1910.        ■•  Journal  of  Nat.  Dent.  Assn.,  March,  1918. 


CHAPTER  XVIII. 
NON-SEPTIC  PERICEMENTITIS. 

Various  grades  of  pericemental  irritation,  ranging  from  a  mild 
arterial  hyperemia  to  actual  inflammation,  may  be  produced  by 
non-septic  causes. 

The  most  satisfactory  evidence  that  inflammation  may  be  so 
caused  is  furnished  by  Talbot's  experiments  with  the  mercurialization 
of  dogs.  Beginning  with  healthy  pericementi,  these  were,  after 
mercurialization  of  the  animal,  found  to  contain  the  round-celled 
infiltration  characteristic  of  inflammation,  and  no  bacteria  could  be 
found.  Further  evidence  is  given  by  the  usual  experimental  study 
of  inflammation  with  the  mesentery  of  the  frog.  Simple  irritation, 
even  with  antiseptic  substances,  produces  the  phenomena.  Any  of 
the  causes  which  may  produce  inflammation  may,  if  acting  in  more 
mild  degree,  produce  arterial  hyperemia.  If  the  action  of  the  cause 
be  violent  and  then  discontinued,  as  in  the  case  of  a  blow,  the  inflam- 
mation resulting  is  acute,  but  may  pass  into  a  chronic  form;  but  if 
the  cause  continue  to  act  it  produces  a  chronic  inflammation. 

For  purposes  of  description,  non-septic  pericementitis  may  be 
divided,  according  to  its  character,  into  traumatic  and  symptomatic, 
and,  according  to  its  location,  into  apical  and  general. 

TRAUMATIC  PERICEMENTITIS. 

By  traumatic  pericementitis  is  meant  a  profound  irritation  of  the 
pericementum,  the  result  of  mechanical  violence  applied  externally 
to  the  tooth,  or  of  instrumentation  or  chemical  irritation  of  the 
pericementum  through  the  root  canal. 

Causes.^ — ^\^iolence  Externally  Applied.^ — Blows  or  falls  deliver 
a  force  expended  upon  the  pericementum  and  alveolar  bone  whether 
received  upon  the  teeth  or  indirectly.  Light  blows  produce  peri- 
cementitis, heavy  ones  may  cause  fracture  or  partial  or  complete 
dislocation  of  teeth  or  fracture  of  alveolar  bone.  A  severe  degree  of 
pericementitis  becomes  subordinate  to  the  major  accident. 

The  biting  of  hard  substances  may  fracture  teeth  (see  page  225)  and 
like  biting  of  threads  delivers  a  short  sharp  blow  upon  the  peri- 
cementima.  Overmalleting  in  building  fillings  is  a  similar  cause. 
(568) 


TRAUMATIC  PERICEMENTITIS  569 

Malocclusion,  especially  overocclusioii,  due  to  overfull  fillings  or  crowns 
when  occlusal,  increases  the  length  and  throws  the  force  of  the  jaw 
upon  that  tooth,  when  approxijnal  it  produces  a  similar  effect  by 
throwing  cusps  of  teeth  into  malocclusion.  The  same  eft'ect  is  tem- 
porarily produced  by  wedges  of  rubber  or  wood,  with  least  tape  and 
traction  cord  and  as  a  rule  orthodontia  usually  has  a  similar  effect 
if  rapidly  done.  ^Malocclusion  due  to  natural  irregularity,  so  to  speak, 
only  exceptionally  produces  this  condition,  but  malocclusion  due  to 
extractions  and  tipping  may  produce  it  usually  in  a  mild  form  leading 
to  slow  degeneration  of  the  pericementum  (see  page  587).  When  ex- 
tractions leave  so  few  teeth  that  the  others  are  overused  non-septic 
pericementitis  supervenes.  Occlusion  leading  to  this  result  has  been 
called  "traumatic  occlusion."  The  looseness  of  a  tooth  from  any 
loss  of  alveolar  support  as  in  resorption  due  to  calculus  or  pyorrhea 
alveolaris  means  increased  movement  under  ordinary  forces  of  masti- 
cation and  the  mechanical  production  of  non-septic  pericementitis. 

The  overstrain  of  a  pericementum  by  clasping  or  the  use  of  insuffi- 
cient piers  for  bridge  w^ork  or  its  improper  occlusion  all  produce 
non-septic  pericementitis.  These  conditions  will  have  further  con- 
sideration.    (See  Overuse  and  ^lalocclusion,  page  588.) 

The  use  of  clamps  or  ligatures  has  produced  gingivitis  with  which 
more  or  less  pericementitis  may  occur.  This  injury  may  cause  much, 
even  permanent  injiu-y  or  mild  injury  only. 

Pathology  of  Traumatic  Pericementitis.— There  is  inflammation  with- 
out pus  formation  in  the  non-septic  area.  In  more  marked  cases 
there  is  considerable  bruise  and  consequent  swelling  causing  extru- 
sion. Not  infrequently  the  tooth  is  permanently  elongated.  Fre- 
quently a  severe  non-septic  pericementitis  is  harder  to  ciu-e  than  a 
septic  one  and  degenerative  changes  may  set  in  if  chi-onic.  If  fracture 
occur  and  infection  follows  a  true  alveolar  suppuration  may  occur. 
In  some  cases  the  blows  cause  pulp  death  and  if  sepsis  enter  apical 
abscess  may  follow  upon  the  alveolar  infection. 

Complicated  hy  Sepsis. — Flaring  or  deeply  placed  gold  bands,  or  any 
foreign  body  under  the  gum  margin  (see  list  of  Causes  of  Gingivitis, 
page  603),  may  produce  mechanical  irritation  so  invariably  accom- 
panied by  septic  complication  that  the  production  of  a  septic  marginal 
pericementitis  as  well  as  gingivitis  is  inevitable.  However,  when 
removed  the  case  rapidly  cures  so  that  the  traumatic  factor  must  be 
considered  paramount,  i.  e.,  sepsis  is  implanted  upon  non-sepsis. 
Likewise  any  case  of  lateral  chronic  non-septic  pericementitis  may  be 
complicated  by  sepsis  at  the  gingival  margin  and  eventually  lead  to 
pyorrhea  (in  the  broad  acceptation  of  the  term).  Also  a  pyorrhea 
pocket  while  causing  a  septic  pericementitis  at  the  point  infected 


570  NON -SEPTIC  PERICEMENTITIS 

must  necessarily  be  accompanied  by  a  zone  of  non-septic  perice- 
mentitis higher  up  and  to  which  resorption  of  bone  or  roots  are 
referable.     (Read  page  588.) 

Symptoms  and  Diagnosis. — If  the  tooth  is  tender  to  touch  or  tapping 
the  pericementitis  is  more  or  less  severe  according  to  the  rebellion 
of  the  patient  and  force  necessary  to  elicit  the  symptom.  The  gum 
may  be  swollen  and  red  or  not.  If  not  and  tapping  is  required  to 
elicit  response,  the  case  is  a  mild  one.  The  fact  that  the  tooth  may  be 
vital  and  an  external  cause  found  as  described  puts  the  case  in  this 
class.  Malocclusion  is  noted  by  means  of  carbon  paper  if  slight  by 
tooth  movement  or  occlusion  if  profound.     (See  Malocclusion.) 

Prophylaxis. — ^All  forms  of  external  violence  should,  if  possible,  be 
avoided  when  deliverable  by  the  operator,  but  accidental  violence 
cannot  be.  However,  as  to  biting  nuts,  thread,  etc.,  patients  should 
be  warned.    Malocclusion  should  be  corrected. 

Prognosis. — Traumatic  pericementitis  in  high  degree  in  the  young 
may  be  recovered  from;  but  in  the  middle-aged  and  aged  it  may  give 
rise  to  a  series  of  degenerative  changes  which  end  only  with  the  loss  of 
the  tooth. 

In  cases  due  to  looseness  of  the  teeth,  of  course,,  septic  primary 
causes  have  to  be  considered,  but  the  pericementitis  may  be  quite 
as  much  mechanically  as  septically  produced. 

In  all  cases  the  extrusion  caused  by  the  inflammation  adds  another 
exciting  cause  of  non  septic  pericementitis — i.  e. ,  malocclusion,  which 
aggravates  the  condition. 

Treatment. — ^The  removal  of  the  cause  is  paramount.  In  case  of 
violence  from  a  single  cause  as  a  blow,  etc.,  only  the  effects  can  be 
treated.  In  mild  cases  of  this  type  sedation  of  the  gum  is  indicated 
by  the  application  to  the  gum  of  cotton  or  gauze  saturated  with  cold 
aqueous  hamamelis  or  boric  acid  solution  may  be  added  (equal  parts) 
to  prevent  sepsis  in  cases  of  possible  fracture.  Cold  applications  or 
bandages  on  the  face  or  the  ice-bag  are  always  applicable.  If  fracture 
and  suppuration  have  occurred  this  requires  syringing  of  the  part 
with  antiseptic  liquids  and  the  above  sedation.  Derivation  is  always 
valuable  in  any  such  case  (see  page  527).  Causes  of  malocclusion 
should  be  removed.    In  orthodontia  milder  force  should  be  used. 

If  the  cause  be  some  mechanical  irritant  at  the  gum  margin,  this 
should  be  removed  and  the  case  treated  as  described  for  gingivitis. 

The  second  principle  of  surgery  is  rest.  This  is  required  in  all 
severe  cases. 

As  a  preliminary  measure  the  tooth  is  gently  but  firmly  lashed 
to  its  neighbors  by  means  of  ligatures  so  that  it  is  rigidly  held.  Splints 
may  occasionally  be  necessary,  but  ordinarily  varnish,  zinc  phos- 


TRAUMATIC  PERICEMENTITIS  571 

phate  or  Kowarska's  paste  may  be  used  to  stiffen  the  ligature.  (See 
Pyorrhea.)  A  swaged  cap  is  to  be  fitted  to  a  neighboring  tooth  to 
prevent  occlusion. 

In  cases  involving  several  teeth,  such  as  all  of  the  incisors,  two 
metallic  plates  are  quickly  swaged  over  metal  models  of  the  teeth 
to  cover  posterior  teeth  and  raise  the  bite,  and  they  are  cemented 
in  position  to  relieve  the  irritated  teeth  from  occlusion. 

Violence  Internally  Applied. — If  a  wholly  or  partially  vital 
pulp  be  torn  from  its  apical  connections,  as  in  the  use  of  pressure 
anesthesia,  an  apical  traumatic  pericementitis  may  be  set  up.  This 
is  usually  transient.  Secondary  hemorrhage  may  occur  and  produce 
pericementitis. 

Excessive  laceration  of  the  apical  tissue  by  means  of  barbed 
instruments,  the  inclusion  of  air  or  medicament  under  a  root  dress- 
ing or  filling,  the  same  exercising  pressm-e  upon  the  apical  tissues; 
the  same  caused  by  biting  on  a  temporary  stopping,  covering  such  a 
dressing;  the  mechanical  irritation  of  a  projecting  root  filling,  pivot 
wire,  broach,  or  drill,  are  all  sufficient  causes  and  should  be  borne  in 
mind  with  intent  to  avoid  but  cannot  always  be  avoided. 

The  undue  enlargement  of  the  apex  of  the  root  canal  or  the  passage 
of  a  reamer  through  the  lateral  aspect  of  a  root  may  excite  inflam- 
mation, and  the  perfect  filling  of  the  opening  may  be  exceedingly 
difficult,  so  that  if  the  tissues  are  not  infected  at  the  time,  sepsis 
may  later  foUow.     Asepsis  is  in  order. 

Cases  due  to  perforation  of  the  root  and  wounding  of  the  peri- 
cementum, after  the  acute  symptoms  have  passed,  commonly  assume 
an  irritative  and  chronic  type,  the  soft  tissues  included  in  the  per- 
foration being  in  a  state  of  chronic  inflammation.  Many  of  these 
cases  become  infected  owing  to  the  difficulty  of  completely  sterilizing 
the  apical  portion  of  the  canal  which  lies  beyond  them. 

The  pericementitis  produced  by  pressure  of  included  air,  liquid, 
or  plastic  root  filling  upon  the  apical  tissue  is  often  severe.  Upon 
removal  of  the  root  dressing  or  filling  the  engorgement  is  relieved 
by  the  gushing  of  blood  through  the  root  canal.  The  inflammation 
may,  however,  continue  unless  sedatives  be  applied  to  the  apical 
tissue  via  the  canal. 

Chemical  Ieritation. — Externally  caustics  applied  at  the  gum 
margins  may  produce  a  gingivitis  with  which  pericementitis  may  be 
involved.  The  application  of  arsenic  to  a  perforation  may  excite  in- 
flammation and  necrosis,  which  endangers  the  jaw.  (See  page  443.) 
The  use  of  arsenic  as  a  pulp  devitalizer  may  cause  a  hyperemia  of  the 
apical  tissue,  following  the  hyperemia  of  the  pulp,  and  causing  slight 
tooth  extrusion,  which  is  aggravated  by  the  malocclusion.    As  stated, 


572  NON-SEPTIC  PERICEMENTITIS 

pulp  hj^Deremias  of  any  sort  may  act  thus  (see  page  403).  This  is 
not  dangerous.     (See  page  435.) 

The  undue  use  of  escharotics,  such  as  carboHc  acid,  sodium  dioxid. 
sodimn  and  potassium  alloy,  zinc  chlorid,  sulphuric  acid,  or  mer- 
curic chlorid,  in  a  pulp  canal  may  excite  an  undesirable  irritation. 
The  limited  irritation  following  their  limited  use  is  often  more  than 
offset  by  the  advantages  of  the  asepsis  produced. 

One  may  ^'iew  such  an  irritation  with  equanimity  if  asepsis  and 
later  comfort  be  attained  in  tissue  already  diseased  as  in  apical  granu- 
lomata  or  abscess,  while  in  normal  tissue,  as  after  pressure  anesthesia, 
irritation  should  be  avoided. 

Diagnosis. — ^The  fact  of  pericementitis  is  obtained  together  with 
the  degree  of  severity  as  in  other  traumatic  cases,  but  the  root  canal 
has  a  described  or  known  history,  or  radiography  establishes  the  facts 
as  related  under  the  causes. 

While  in  fresh  cases  the  diagnosis  is  fairly  easy  owing  to  known  facts 
in  all  cases  only  the  absence  of  pus  or  a  similar  effect  indicates  non- 
sepsis  and  in  any  case  infection  may  really  be  present  unknown  to  the 
operator  unless  a  laboratory  test  be  made.  In  case  of  doubt,  it  is 
better  to  assume  sepsis  rather  than  make  the  test. 

Treatment. — ^^Vhen  the  apical  tissues  have  been  irritated  by  way  of 
the  canal,  after  the  cause  has  been  removed  and  the  tooth  canal  made 
operable,  sedatives,  such  as  tincture  of  aconite  or  menthol  in  chloro- 
form, phenol-camphor,  eugenol,  or  menthol-phenol  (menthol,  3  parts; 
carbolic  acid,  1  part;  melted  together)  should  be  applied  on  cotton  to 
the  apical  tissue  by  way  of  the  root  canal.  Novocain  may  be  added 
to  any  sedati^•e  oil.  iUl  cases  of  traumatic  pericementitis  of  this  type 
require  the  persistent  use  of  counter-irritants,  applied  every  other  day 
to  the  overlying  gum.  (See  page  391.)  In  cases  in  which  the  gum 
over  the  tooth  is  already  inflamed  this  is  not  to  be  applied  over  the 
tooth  but  dental  tincture  of  iodin  is  "spotted"  around  the  area. 

Systemic  derivation  is  also  useful  in  the  acute  cases.  In  even 
mild  cases  the  guarding  of  the  extruded  tooth  against  malocclusion 
is  of  advantage.     (See  page  527.) 

SYMPTOMATIC  NON-SEPTIC  PERICEMENTITIS. 

By  sjTuptomatic  non-septic  pericementitis  is  meant  an  aseptic 
pericementitis  occurring  as  the  result  of  systemic  conditions,  or  of 
the  action  of  drugs  taken  internally. 

If  mercury  be  administered  to  patients  in  large  doses  for  long 
periods,  or  in  one  or  more  massive  doses,  or  if  the  patient  have  an 
idiosyncrasy  to  the  action  of  this  agent,  or  be  a  worker  in  mercurials, 


SYMPTOMATIC  NON-SEPTIC  PERICEMENTITIS  573 

an  irritation  of  the  salivary  glands  is  excited,  followed  by  looseness 
and  soreness  of  the  teeth  and  swelling  of  the  gums;  that  is,  a  general 
pericementitis  and  maxillary  periostitis  arise.  The  patient  has  a 
metallic  copper}?^  taste,  coated  tongue,  and  fetid  breath;  the  gums 
are  puffy  and  bleed  easily.  In  advanced  cases  the  tongue  and 
cheeks  are  swollen.  Talbot's  experiments  on  dogs  show  conclu- 
sively that  a  true  pericementitis  may  be  induced  owing  to  the 
chemotactic  properties  of  the  mercury  alone.  (See  Interstitial 
Gingivitis.)  Potassium  iodid  administered  in  this  condition  relieves 
the  maxillary  periostitis  and  pericementitis;  but  the  same  drug 
administered  in  health,  or  for  conditions  other  than  mercurial 
poisoning,  also  causes  irritation  of  the  pericementum.  Pilocarpin 
has  a  similar  effect,  though  in  much  less  degree.  All  of  these  drugs 
are  partially  eliminated  by  the  glandular  appendages  of  the  mouth, 
and  during  elimination  apparently  act  as  local  irritants.  Lead 
poisoning  may  have  a  similar  action.  A  blue  line  appearing  on  the 
gums  is  symptomatic.  It  occurs  in  painters  and  workers  in  lead. 
Lead  has  been  found  in  the  calculus  on  the  teeth  and  even  in  the 
tooth  substance. 

Patients  who  have  a  gouty  heredity,  or  who  are  the  subjects  of 
active  gout,  frequently  exhibit  a  tenderness  of  the  entire  pericemen- 
tum of  one  or  more  or  sometimes  all  of  the  teeth.  This  pericemental 
disturbance  may  be  the  precursor  of  an  acute  outbreak  of  gout  in 
the  metatarsophalangeal  joint. 

Scurvy — a  now  rare  systemic  disease,  due  to  prolonged  absence  of 
vegetable  diet — is  attended  by  rapid  inflammatory  degeneration  of 
the  pericementimi  of  the  teeth  and  of  the  alveolar  tissues.  The  gums 
are  swollen  and  the  teeth  if  loosened  may  fall  out. 

Syphilis  is  also  attended  by  pericemental  irritation.  This,  of 
course,  is  of  septic  origin. 

In  auto-intoxication  by  intestinal  toxins  or  by  leukomains  in 
diseases  involving  general  malnutrition,  the  irritants  are  probably 
in  part  eliminated  by  the  gums,  which  are  in  turn  irritated.  (See 
Interstitial  Gingivitis  and  Pyorrhea  Alveolaris  for  further  discussion.) 

It  has  been  shown  by  Loup  that  mercurial  stomatitis  may  be 
cured  by  mercury  used  as  an  oral  antiseptic;  therefore,  the  logical 
conclusion  is  that  oral  organisms  play  a  part  in  the  production  of 
the  local  effects  of  mercury  as  is  probable  in  many  cases  of  systemic 
disease  having  oral  sAinptoms  (see  pages  618  and  620)  probabh' 
the  mercury  produces  a  local  predisposition.  This  is  fm-ther  confirmed 
by  the  fact  that  if  the  teeth  are  attended  to  and  oral  prophylaxis 
practised  before  the  administration  of  mercury  to  syphilitics,  they 
tolerate  greater  amounts  of  the  drug  before  salivation  or  stomatitis. 


574 


NON-SEPTIC  PERICEMENTITIS 


Touching  this  point  Hartzell  and  Henrici^  fed  cats  with  calomel, 
producing  mercurial  stomatitis  with  loosening  of  teeth  and  abscesses 
from  which  and  from  the  cervical  lymph  nodes  streptococci  were 
isolated  (thus  showing  the  action  of  oral  streptococci  upon  tissue 
with  reduced  resistance). 

Treatment. — ^The  drug  should  be  discontinued,  the  disease,  if 
present,  should  be  antagonized,  being  referred  to  a  physician,  and  the 
local  complications,  if  any,  should  be  appropriately  treated,  antisepsis 
being  always  advisable.  If  the  pericementitis,  gingivitis,  and  stoma- 
titis be  mercurial,  the  drug  should  be  stopped  and  an  antisialagogue 
used,  such  as  atropin  sulphate,  f-^  gr.  each  four  to  six  hours,  until 
relieved. 

Potassium  chlorate  as  a  mouth  wash,  or  internally,  is  useful  if  the 
stomach  is  not  irritable. 

I^ — Potassii  chloratis gr.  xlviij 

Tr.  myrrhse f  3ss 

Elixir  calisayse q.  s.  ad  fgiij — M. 

Sig. — Teaspoonful  every  five  hours,  or  use  as  a  mouth  wash.     (Hare.) 

Results  of  Chronic  Non-septic  Pericementitis. — If  at  any  point  of 
the  irritated  pericementum  a  constructive  grade  of  irritation  be 
maintained,  the.cemental  tissue  becomes  hypertrophied  (Fig.  550). 


Fig.  550 


If  a  more  severe  grade  of  irritation — i.  e.,  low-grade  inflammation 
— be  present  for  a  long  time,  the  cementum  and  even  the  dentin 
of  the  root  may  be  resorbed.  Both  of  these  results  may  go  on 
concurrently  at  different  points,  or  resorption  may  be  followed  by 
deposition  of  cementum  if  the  conditions  change.  Even  when 
primary  causes  are  septic  and  a  septic  inflammation  ensues,  beyond 
the  area  of  active  inflammation  there  always  exist  non-septic  areas 
having  cell  activity  competent  to  construct  or  destroy  by  resorption. 
(See  Granuloma.) 


1  Jour.  Nat.  Dent.  Assn.,  May,  1917,  p.  496. 


H  YPERCEMENTOSIS 


575 


HYPERCEMENTOSIS   (DENTAL  EXOSTOSIS,  EXCEMENTOSIS, 
HYPERPLASIA  OF  THE  CEMENTUM). 

Definition. — By  hypercementosis  is  meant  a  secondary  deposit,  or 
an  increase  of  volume  of  the  cementum  of  a  tooth  beyond  the  normal 
limit.     It  may  be  circumscribed  or  diffuse. 

Causes. — A  constructive  degree  of  hyperemia  or  very  mild  inflam- 
mation is  the  proximate  cause,  which  may  be  excited  by  numerous 
primary  causes,  such  as  a  projecting  root  filling,  a  projecting  edge  of 
crown  filling,  deposist  of  salivary  calculus,  the  overlapping  of  a  cavity 
margin  by  the  gum,  malocclusion,  non-occlusion,  the  biting  of  hard 
objects,  such  as  nuts  or  thread,  the  overuse  of  certain  teeth,  the 
habitual  tapping  together  of  teeth,  the  habitual  chewing  of  tooth- 
picks, the  gradual  pressure  of  gas  from  dead  pulps.  The  pressure  of  a 
tooth  root  against  another  root  during  eruption  is  a  sufficient  cause. 
(See  Fig.  74.)  The  overcrowding  of  teeth  in  an  arch  has  also  caused 
this  condition,  as  has  also  the  impaction  of  a  tooth  (Fig.  169) .  Chronic 
alveolar  abscess  or  pyorrhea  alvealaris  may  cause  it  by  inducing 
about  itself  at  a  distance  an  area  of  h}^eremia.  (Aseptic  Zone.)  It 
also  seems  at  times  to  be  induced  after  pulp  devitalization  from  any 
cause.  Hypercementosis  is  a  possibility  in  any  case  of  chronic  peri- 
cemental irritation  competent  to  maintain  constructive  cementoblast 
activity;  it  represents  a  degree  of  irritation  rather  than  any  one 
specific  cause.  It  has  been  discussed  by  some  writers  under  the 
heading  of  Constructive  or  Condensing  Pericementitis,  and  is 
analogous  to  subperiosteal  deposition  of  bone  especially  in  the  form 
of  a  true  exostosis  or  to  osteosclerosis.     (See  page  49.) 

Fig.  551 


Hypercementosis.    Outline  of  antrum  well  shown.     (Radiograph  by  Lodge.) 


Situation. — Hypercementosis  may  be  diffused  over  almost  an 
entire  root  or  several  roots,  or  be  localized  as  a  distinct  nodule  at 
some  lateral  aspect,  or  exist  as  a  circumscribed  enlargement  about 


576  NON-SEPTIC  PERICEMENTITIS 

the  apex  of  a  root,  or  at  the  neck  of  a  root.  It  is  always  located 
where  the  cause  (hyperemia)  has  been  produced  (Fig.  551). 

Flagg  noted  that  75  per  cent,  of  cases  of  hypercementosis  were 
found  upon  posterior  teeth,  and  that  the  teeth  were  usually  of  the 
character  termed  dense — i.  e.,  the  tissues  of  the  individual  were  of 
recuperative  type,  tending  to  produce  constructive  changes. 

Pathology  and  Morbid  Anatomy. — For  some  time  after  eruption 
the  cementum  consists  of  but  few  lamellae  of  deposit.  It,  however, 
reaches  a  maximum  normal  development  at  which  it  normally  rests, 
as  in  the  case  of  the  physiological  pulp  cavity.  As  age  progresses 
it  is  apt  to  be  more  thickly  deposited  at  the  expense  of  the  peri- 
cementum, which  becomes  more  attenuated.     Whether  this  is  due  to 

Fig.  552 


/; 


i 


M^^\M:^v^\\\^^^^^\\^^\^\^v\  ^\lu\lll\^^^^ 


Hypertrophy  of  the  cementum  on  the  side  of  a  root  of  a  lower  molar  near  the  neck 
of  the  tooth  of  a  man:  a,  dentin;  h,  cementum;  c,  fibers  of  peridental  membrane;' 
from  6  to  c  the  cementum  is  normal  and  the  incremental  lines  fairly  regular,  but  at 
d  one  of  the  lamellae  is  greatly  thickened;  at  e  this  lamella  is  seen  to  be  about  equal 
in  thickness  with  the  others.  The  next  two  lamellae  are  thin  over  the  greatest  prom- 
inence, but  one  is  much  thickened  at  g,  and  both  at  h.  These  latter  seem  to  partially 
fill  the  valleys  which  were  occasioned  by  the  first  irregular  growth.  From  a  length- 
wise section.     (Black.) 

irritants  floating  in  the  blood  stream,  or  to  the  various  local  irritants 
above  mentioned,  to  long  continued  use  of  the  teeth,  or  to  perfectly 
normal  development,  is  not  clear  except  for  certain  definite  cases. 
Increased  density  of  cementum  may  also  be  attributed  to  a  similar 
pathology. 

Nodular  and  irregular  forms  arising  from  the  general  surface  are 
clearly  of  abnormal  type. 

Successive  lamellae  are  deposited;  the  pericementum  recedes, 
causing  resorption  of  the  alveolar  process.  Union  of  the  bone  and 
cementum  (ankylosis)  very  rarely  occurs.  A  resorption  of  cementum 
and  dentin  may  occur  at  some  point  owing  to  a  different  degree  of 
irritation,  and  in  the  area  a  new  deposition  of  cementum  may  occur 


HYPERCEMENTOSIS 


577 


(Fig.  553,  d).  In  some  cases  distinct  areas  of  hypercementosis  and 
root  resorption  are  seen  in  close  proximity.  Chronic  apical  abscess 
may  produce  a  denudation  of  the  root  end,  and  a  short  distance 
below  at  a  point  about  at  which  the  sac  is  attached  and  at  which  the 
zone  of  hj^eremia  would  be  present,  an  annular  ridge  of  hyper- 
cementosis may  occur.  These  are  distinctly  noted  in  granulomata  (at 
times  after  extractions) .  Areas  of  hypercementosis  may  be  translucent 

Fig.  553 


a  h 
Apex  of  root  of  an  upper  bicuspid  tooth  with  irregularly  developed  cementum; 
a,  a,  dentin;  b,  b,  pulp  canals.  The  lamellae  of  cementum  are  marked  1,  2,  3,  etc.; 
d,  d,  d,  absorption  areas  that  have  been  refilled  with  cementum.  It  will  be  seen  that 
the  apices  of  the  roots  were  originally  separate,  but  became  fused  with  the  deposit 
of  the  second  lamella  of  cementum,  and  that  in  this  regular  growth  began  and  was 
most  pronounced.  It  has  continued  through  the  subsequent  lamellae  but  in  less  degree. 
It  will  also  be  noticed  that  the  absorption  areas,  d,  d,  d,  have  proceeded  from  certain 
lamellae.  That  between  the  roots  has  broken  through  the  first  lamella  and  pene- 
trated the  dentin,  and  has  been  filled  with  the  deposit  of  a  second  lamella.  Other 
of  the  absorptions  have  proceeded  from  lamellae  which  can  be  readily  made  out.  The 
small  points,  e,  seem  to  have  been  filled  with  the  deposit  of  the  last  layer  of  cementum, 
while  others  have  one,  two,  or  more  layers  covering  them.     (Black.*) 


or  decidedly  opaque,  and  sometimes  the  two  are  combined,  a  mottled 
appearance  being  produced,  which  corresponds  to  the  constructions  by 
the  pulp  in  cases  of  secondary  dentin  and  pulp  nodule  (see  page  365) . 
If  the  growth  proximate  another  root,  the  pericementum  may 
resorb  at  the  point  of  contact  and  a  deposition  of  cementum  occur 
which  firmly  unites  the  roots  in  a  union  called  concrescence.  (See 
Fig.  160.) 
37 


578  NON-SEPTIC  PERICEMENTITIS 

It  has  occurred  that  a  root  filling  protruding  through  a  perforation 
has  caused  a  diffused  exostosis  of  the  alveolar  process.'  The  hyper- 
trophied  process  may  be  ivory-like  in  hardness. 

Symptoms  and  Diagnosis. — Many  cases  exist  without  active  local 
symptoms.  In  no  case  is  the  color  of  the  gum  altered  unless  other 
disease  than  hyperemia  be  acting  as  a  cause.  In  some  cases  there 
are  sjonptoms  of  hyperemia  expressed  as  a  disposition  to  bite  hard 
upon  the  particular  tooth,  or  to  grind  upon  it.  A  paroxysm  of  gnaw- 
ing pain  lasting  for  some  hours,  and  recurring  at  intervals,  is  also 
somewhat  characteristic.  SjTiipathetic  hyperemia  of  the  pulp  with 
increased  response  to  thermal  changes  may  occur.  (See  page  388.) 
The  gum  may  have  slightly  receded. 

Neuralgia,  functional  blindness,  functional  deafness,  chorea, 
epileptiform  fits,  paralysis,  cardiac  neuralgia,  insanity,  and  other 
related  conditions  have  been  cured  by  the  extraction  of  hj^er- 
cementosed  teeth. ^  Milder  sjonptoms  of  like  character  may  of  course 
occur. 

The  treatment  of  teeth  presenting  obstinate  symptoms  of  peri- 
cementitis, apparently  due  to  putrefaction  of  the  pulp,  may  at  times 
be  complicated  by  unsuspected  hypercementosis  and  closure  of  the 
apical  foramen  may  possibly  be  due  to  formations  by  the  enclosed 
tissue. 

In  such  cases,  if  pulp  or  pericemental  complication  cannot  be 
determined,  suspicion  should  point  to  hypercementosis  and  an  a;-ray 
examination  be  made,  by  which  means  the  condition  may  be  posi- 
tively determined.  As  entire  dentures  have  been  extracted,  tooth 
by  tooth,  in  a  vain  endeavor  to  cure  a  neuralgia  about  the  head, 
this  means  of  diagnosis  should  not  be  overlooked. 

Treatment. — The  treatment  for  hypercementosis  may  first  be  a 
conservative  one  if  only  slight  annoyance  be  produced  by  it. 

Removal  of  a  cause  if  found  and  counterirritation  may  be  employed. 
The  symptoms  may  disappear.  If  they  do  not,  or  they  are  severe 
when  the  patient  applies,  the  tooth  should  be  completely  extracted. 
The  operation  of  apicoectomy  may  be  safely  tried  for  apical  hyper- 
cementosis. The  bulbous  condition  of  the  root  end  may  cause 
extraction  to  be  difficult,  and  fracture  of  the  root  end  may  occur 
(or  the  alveolar  wall  may  fracture).  Flagg  recommended  that  in 
such  a  case  a  fissure  drill  be  passed  about  the  circumference  of  the 
root  end  to  remove  the  bony  obstruction  to  its  passage  out  of  the 
alveolus,  after  which  it  may  be  lifted  away  with  tweezers.  In  another 
method  the  root  may  be  perforated  by  a  drill  and  then  divided  into 

1  Garretson's  Oral  Clinic,  1884. 

2  Brubaker.     American  System  of  Dentistry, 


ANKYLOSIS 


579 


two  sections  by  means  of  a  dentate  fissure  bur,  after  whicb  the  halves 
may  be  pushed  together  with  a  small  elevator.  If  not  then  removable 
the  fissure  bur  can  now  easily  enlarge  the  alveolar  constriction.  In  a 
third  method  an  opening  through  the  alveolar  wall  similar  to  that 
for  apicoectomy  may  be  employed.  Local  anesthesia  is  indicated. 
The  use  of  alveolar  forceps  for  the  condition  is  little  short  of  brutal, 
and  only  warranted  by  the  impracticability  of  other  means. 

Fig.  554 


Nodular  hypercementosis  on  distal  at  first  curve  caused  fracture. 

alveolar  process. 


Removed  by  drilling 


Extraction  for  hj'percementosis  may  cause  considerable  bruising 
of  the  walls  of  the  alveolus,  followed  by  inflammation  accompanied  by 
excruciating  pain  lasting  often  for  days.  The  alveolus  may  refuse  to 
granulate,  and  a  septic  condition  result.  The  pain  may  at  times  be 
relieved  by  the  injection  of  a  2  per  cent,  solution  of  novocain  into  the 
giun  on  both  sides  of  the  alveolus.  After  the  surfaces  of  the  alveolar 
walls  have  been  sterilized  as  well  as  possible  they  are  then  burred 
away  until  tissue  capable  of  granulation  is  reached. 

The  alveolus  should  then  be  irrigated  and  a  clot  invited  by  causing 
a  slight  hemorrhage.  The  case  is  continued  as  for  "dry  socket"  if  the 
clot  break  down.     (See  page  564.) 

ANKYLOSIS   (SYNOSTOSIS). 

By  this  is  meant  the  union  of  bone  and  cementum,  a  condition 
analogous  to  ankylosis  of  bone. 

Hopewell-Smith^  has  described  5  cases,  of  which  he  ofi^ers  the 
following  explanation:  (1)  inflammation  occurs  and  the  membrane 
is  changed  into  granulation  tissue;  (2)  the  cellular  elements  destroy 
portions  of  the  bone  and  excavate  the  cementum;  (3)  the  mass  of 
granulation  tissue  is  then  ossified,  joining  the  bone  and  cementum 
in  a  firm  union. 


Histology  and  Pathohistology  of  the  Teeth. 


580 


NON-SEPTIC  PERICEMENTITIS 


E.  C.  Rice^  has  reported  a  case  of  a  lady  for  whom  an  implantation 
of  an  upper  bicuspid  was  done.  In  an  eflfort  made  later  to  remove 
the  tooth  all  attempts  to  loosen  it  in  any  degree  with  forceps  failed. 


Fig.  555 


Resorption  of  roots,  with  immobility  (see  text). 
Fig.  556 


R 


Vertical  section  of  a  human  tooth  ankyloscd  to  the  jaw:  R,  root;  B,  bone  of  jaw. 
The  absolute  continuity  of  the  two  hard  tissues  is  strikingly  shown.  From  the  col- 
lection of  the  late  Stoi'er  Bennett. ^    (Hopewell-Smith.) 


In  my  own  practice  an  implanted  tooth  was  firmly  immovable 
in  any  degree,  though  ten  years  in  place  :2  The  union  may  not  be 
a  true  ankylosis  in  these  cases,  though  doubtless  bone  has  entered 

1  Private  communication. 

2  This  tooth  has  later  fractured  and  the  root  was  removed  by  division  with  a  root 
reamer  and  the  halves  collapsed  with  an  elevator.    There  seemed  to  be  no  resorption, 

•'  Transactions  of  the  Odontological  Society  of  Great  Britain. 


RESORPTION  OF  THE  ROOTS  OF  PERMANENT  TEETH     581 

areas  of  previous  resorption.  A  remarkable  case  was  shown  the 
editor  by  Dr.  J.  Curr}'',  of  Philadelphia.  Every  pier  tooth  of 
four  bridges  was  firmly  ankylosed  and  immovable,  yet  large  bays 
of  resorption  in 'each  root  necessitated  extraction.  This  was  not  a 
plantation  case.     Fig.  555  a  and  b  shows  two  of  the  teeth. 

RESORPTION  OF  THE  ROOTS  OF  PERMANENT  TEETH. 

By  resorption  of  the  roots  of  permanent  teeth  is  meant  the  gradual 
removal  of  the  cementum  and  dentin  of  permanent  roots  by  phago- 
cytic cells  existing  in  the  adjacent  soft  tissue  (osteoclasts).  When 
occurring  as  the  result  of  pressure  by  another  tooth  a  tissue  similar 
to  an  absorbent  organ  (Figs.  44,  45),  as  in  resorption  of  deciduous 
teeth,  is  probably  developed  between  them. 

Causes. — ^The  proximate  cause  is  probably  in  all  cases  a  degree  of 
irritation  greater  than  that  required  to  produce  hypercementosis. 
Probably  a  mild  non-septic  inflammation  exists  or  if  septically  pro- 
duced the  tissue  is  capable  of  cell  activity.  Certain  granulomas  show 
macrophages  present.  (Thoma.)  That  an  aseptic  inflammation 
causes  resorption  or  at  least  that  infection  is  not  necessary  is 
shown  by  a  specimen  of  Endelman's  (Fig.  542.)  in  which  inflamma- 
tory elements  are  sho\\ai  outside  the  fibrous  capsule  of  a  granulorna 
which  he  has  shown  in  several  instances  did  not  produce  infection 
of  media  from  outside  while  its  contents  did  (see  page  557). 
Talbot's  demonstrations  of  interstitial  gingivitis,  a  term  meant  to 
include  interstitial  pericementitis,  show  that  it  is  a  frequent  cause  of 
both  root  and  alveolar  resorption.  (See  Deeply  Seated  Gingivitis.) 
In  other  words,  it  is  due  mainly  to  an  aseptic  pericementitis  at  the 
point  of  resorption  though  the  primary  cause  may  be  septic,  i.  e., 
resorption  occurs  in  the  zone  of  lesser  inflammation  inside  of  the  zone 
of  hyperemia  and  outside  of  the  zone  of  stasis  (see  page  39). 

The  disease  has  been  discussed  by  other  waiters  as  "Rarefying 
Pericementitis,"  fairly  analogous  to  osteoporosis.  (See  page  48.) 
.  Of  primary  causes  chronic  apical  abscess  seems  to  be  a  frequent 
one.  Although  theoretically  the  alkaline  pus  formed  should  neutral- 
ize acid  formation,  the  fact  of  resorption  remains,  and  is  probably 
explainable  upon  the  ground  that  it  is  produced  by  the  granulation 
tissue  formed  about  the  root  apex  during  periods  of  lessened  pus 
formation  or  previously  during  a  granulomatous  period. 

Protruding  root  fillings  or  broaches  are  common  causes  (Fig.  557) . 
A  peculiar  resorption  in  the  cervical  third  of  two  replanted  incisors 
caused  the  fracture  of  one  at  the  point  of  resorption  and  necessitated 
the  removal  of  both  teeth  (Fig.  559) .    Plantations  are  usuafly  followed 


582 


NON-SEPTIC  PERICEMENTITIS 


by  peculiar  resorptions  over  even  the  entire  root.     These  are  often 
filled  in  with  bone  causing  a  rigidity  of  the  root  attachment.    Loose- 


FiG.  557 


Fig.  558 


Fig.  559 


Fig.  557. — Apical  abscess  and  resorption,  produced  by  a  protruding  broach. 

Fig.  558. — Deciduous  cuspid  crowned,  mistaken  for  permanent  cuspid  which  lay 
in  jaw  and  caused  resorption  of  root  of  permanent  lateral.      (Radiograph  by  Price.) 

Fig.  559. — Resorption  at  cervical  third  in  two  replanted  teeth,  one  broken  in 
consequence.    Editor's  practice.     (Radiograph  by  Hagopian.) 


Fig.  560 


Fig.  561 


Case  of  extensive  resorption  about  upper 
central.     (Radiograph  by  Lodge.) 


Resorption  of  roots.     (Radiograph 
by  Lodge.) 


Fig.  562 


Fig.  563 


Distal  root  of  lower  molar  abscessed 
and  resorbed,  probably  during  granulo- 
matous period. 


Oveiused  and  loosened  vital  tooth. 
Root  apex  appears  as  though  first  re- 
sorbed then  hypercementosed. 


RESORPTION  OF  THE  ROOTS  OF  PERMANENT  TEETH     583 

ness  of  a  tooth  with  the  resultant  excess  of  movement  excites  deeply 
seated  gingivitis  and  resorption  of  bone  and  often  of  roots.  Looseness 
of  teeth  from  any  cause  may  cause  more  non-septic  pericementitis, 
looseness  and  resorption,  though  as  a  cause  it  seems  to  produce  slight 
spicular  resorption  rather  than  large  bays.  Partial  luxation  as  the 
result  of  a  blow  or  fall  produces  the  same  result,  the  pericementum 
becoming  thickened,  the  tooth  loosened  and  extruded,  and  mal- 
occlusion, which  is  also  a  cause,  being  induced. 

A  toothpick  broken  off  in  the  gum  tissue  has  produced  resorption 
at  the  neck  of  the  root. 

The  descent  of  a  supernumerary  or  impacted  tooth  upon  a  per- 
manent root  has  caused  resorption,  exposing  the  pulp  of  the  resorbed 
root,  and  producing  pulp  reactions.  This  may  be  quite  extensive 
before  violent  s\Tiiptoms  occur  (Fig.  558).  In  one  case  both  the 
buccal  roots  of  an  upper  molar  were  removed  by  a  supernumerary 
tooth,  the  crowm  of  which  fitted  the  resorbed  root  ends. 

Resorptions  also  occur  in  orthodontia,  as  when  a  cuspid  is  delayed 
and  presses  upon  a  lateral  root.  The  resorption  may  be  more  distant 
than  the  pressure  point.  In  orthodontia  this  may  be  explained 
by  the  extension  of  the  phagocytic  area  or  the  induction  of  such  an 
area  about  moving  teeth;  indeed,  teeth  cannot  be  moved  without 
exciting  a  phagocytic  action. 

Dewey, ^  following  Hertzler,  claims  that  rickets  causing  imperfect 
calcification  of  teeth  is  liable  to  be  a  factor  in  untoward  resorptions 
in  orthodontia,  while  tuberculosis  neither  interferes  with  tooth 
eruption  nor  calcification,  but  may  interfere  with  proper  physio- 
logical resorption  because  the  phagocytes  are  elsewhere  occupied  and 
the  absorbent  organ  is  not  fully  developed. 

Calculus  beneath  the  gum  margin  has  produced  resorption  through 
the  production  of  gingivitis.  In  one  case  noted  four  lower  incisors 
presented  the  characteristic  bays  at  a  point  one-eighth  inch  below 
the  gum  line. 

Some  of  the  cases  exhibit  no  tangible  cause;  the  root  resorbs 
apparently  as  the  result  of  a  peculiar  reaction  upon  the  part  of  the 
tissues  of  the  individual,  who  may  lose  many  teeth  by  this  process — 
i.  e.,  a  dyscrasia  exists.  The  teeth  may  be  non-carious  and  the  pulps 
vital.  In  some  of  these  cases  neurasthenia  or  a  uric  acid  diathesis 
seems  to  have  some  association  with  the  condition  (Fig.  565). 

Pathology  and  Morbid  Anatomy. — Both  resorption  of  cementum 
and  its  redeposition  occur  in  deciduous  teeth  as  physiological  pro- 
cesses; at  some  aspect  of  the  cementum  the  tissue  becomes  hollowed 

1  Items  of  Interest,  May,  1914,  p.  358. 


584 


NON-SEPTIC  PERICEMENTITIS 


out,  and  later  may  be  filled  in  by  new  cementum  which  is  again 
Tesorbed.  Resorption  of  tissue  throughout  the  body  is  accomplished 
by  means  of  multinucleated  cells  (macrophages,  giant  cells,  osteo- 
clasts) .  At  some  part  to  be  physiologically  resorbed  these  cells  make 
then-  appearance  in  contact  with  the  tissue  to  be  removed,  and  it 
gradually  disappears,  the  layer  of  multinucleated  cells  constantly 
occupying  the  excavated  territory  known  as  Howship's  lacunae 
(Fig.  564). 

Fig.  564 


Inflamed  pericementum,  osteoclasts  in  Howship's  lacunae.    (V.  A.  Latham.) 

If  a  foreign  (aseptic)  body  be  introduced  into  living  tissues,  it 
becomes  surrounded  by  these  cells,  which  in  some  cases  effect  its 
removal;  in  others,  failing  to  remove  the  foreign  body,  connective 
tissue  forms  about  it  and  encj^sts  it;  encystment  may  occur  after 
partial  removal  by  giant  cells. 

The  resorption  of  a  root  may  be  of  any  extent,  from  a  slight  spicular 
roughness  of  the  apex  of  the  root  to  almost  complete  removal  of 
the  root. 

Perforation  of  the  root  from  side  to  side  may  occur,  of  course, 
involving  the  pulp  canal,  and,  if  the  pulp  be  alive,  obscure  reactions 
upon  its  part  may  occur  (Fig.  565). 

An  area  of  marked  resorption  may  occur  at  a  point  just  beneath 
the  gum  margin  and  upon  any  aspect  of  the  tooth.     In  this  situation 


RESORPTION  OF  THE  ROOTS  OF  PERMANENT  TEETH     585 

it  may  simulate  a  cavity  of  decay  beneath  the  gmn.  It  occurs 
upon  either  vital  or  devitalized  teeth,  and  may  expose  the  pulp 
or  the  root-canal  filling.  The  gum  tissue  is  usually  found  within  the 
cavity  The  test  of  a  probable  resorption  is  the  grotto-like  character 
of  the  cavity,  the  hard,  rough  inner  surface  and  absence  of  decalcified 
dentin.  Its  surface  dift'ers  from  that  either  of  a  cavity  of  decay  or  an 
erosion.  There  is  in  cervical  cases  open  to  the  mouth  a  possibility  of 
mistake  and  that  destruction  of  decalcified  dentin  by  saprophytic . 
bacteria  has  occurred  as  argued  by  Black  from  cro\sm  cavities  con- 
taining fungous  pulp  tissue  (see  page  417),  on  the  other  hand  even 
this  condition  may  possibly  be  absorption.  These  cervical  grottoes 
resemble  the  large  one  in  Fig.  565,  in  which  case  no  argument  of 
caries  applies. 

It  is  probable  that  in  plantations  the  root  acts  as  an  aseptic  foreign 
body;  mild  inflammation  occurs,  subsides,  and  giant  multinucleated 
cells  attack  the  tooth  root  and  endeavor  to  remove  it  by  solution;  this 
they    accomplish,  in    part,    in    spots;    then  a 
tolerance    is   established    (mild    inflammation  ^^*^-  ^65 

becomes  hyperemia)  and  connective  tissue 
organizes  about  the  roots;  later,  more  com- 
plete regeneration  is  represented  in  the  for- 
mation of  bone;  condition  of  a  bony  fixation 
is  established,  evidenced  by  the  clear  ring- 
ing note  elicited  upon  tapping  the  planted 
tooth. 

■nrT.,1  p  ,  ,•  i?x  1      X  Idiopathic  resorption 

With  reference  to  resorption  after  planta-  of  permanent  root.  The 
tions.  Miller^  records  the  following  results  of     tiay  upon  the  side  ex- 

,  .        ,  , .  rrii       r;       ,  •  £        •        1       x    J       POsed  the  pulp  and  per- 

his  observations,     ihe  fixation  or  reimplanted     forated    the    root    as 
or  transplanted  teeth  mav  be  accomplished  in     shown.    Crater-iike  re- 

,,  "  sorption     about    apical 

three  ways:  foramen.    Pulp  first  de- 

1.  By  simple  encapsulation  of  the  root.  vitalized  on  account  of 

„T->xii  11  r  x'x-  I'l         persistent  pain  and  the 

2.  By  the  bundles  oi  connective  tissue  which     tooth  later  extracted. 
fill  up  irregular  absorption  spaces,  especially 

where  the  pericementum  has  not  been  present  at  that  portion  when 
the  implantation  was  made  (a  pseudo-attachment). 

3.  By  direct  union  of  the  surrounding  tissues  with  the  living 
pericementum.  He  inclines  to  think  this  "the  only  permanent 
attachment. 

He  states  that  for  the  most  part  osteoclasts  were  few  and  that 
resorption  was  carried  on  by  smaU  round  ceUs.  According  to  Ribbert^ 
osteoclasts  are  not  essential  to  resorption  of  bone. 

'  Independent  Practitioner,  1887. 

2  Adami  and  McCrae:  Text-book  of  Pathology. 


586 


NON-SEPTIC  PERICEMENTITIS 


The  inflammatory  reaction  and  resorption  is  least  when  replanta- 
tion is  practised,  but  may  at  times  be  pronounced  in  even  those 
cases.  If  the  socket  of  a  tooth  extracted  for  resorption  be  examined, 
a  mass  of  soft  tissue  will  be  found  occupying  the  locations  corre- 
sponding to  the  areas  of  resorption  (Fig.  566).  No  acid  reaction  can 
be  detected  with  litmus  paper,  but,  nevertheless,  it  is  probable  that 
the  cells  producing  resorption  excrete  an  acid  capable  of  dissolving 
the  tissue. 

There  is  some  evidence  of  this  in  cases  of  enamel  resorption  occur- 
ring upon  the  crowns  of  impacted  teeth  which  have  never  been  in 
relation  with  the  oral  fluids,  and  about  which  there  is  no  evidence  of 
caries  in  the  areas  of  dentin  resorption  also  present.  In  the  fortunate 
specimens  of  these  cases  a  superflcial  decalcification  of  the  enamel 
surface  may  be  seen  which  can  only  occur  as  the  result  of  acid  action. 
(See  page  214.) 


Fig.  666 


Resorption  of  distal  root  of  a  first 
molar.    (Radiograph  by  Custer.) 


Diagram  of  a  case  of  root  resorption 
after  secondary  dentin  had  formed:  SD, 
secondary  dentin;  AR,  area  undergoing 
resorption;  peculiar  central  spire  of  sec- 
ondary dentin  which  has  resisted  the 
resorbent  action.  Specimen  in  possession 
of  Dr.  A.  P.  Fellows. 


Symptoms  and  Diagnosis.— The  tooth  may  present  symptoms 
of  non-septic  pericementitis,  and  may  be  loosened  in  advanced 
cases.  In  the  early  stages  no  looseness  may  be  observed.  In 
more  advanced  cases  a  strain  suddenly  applied  causes  a  luxation; 
thereafter  the  tooth  progressively  loosens. 

The  condition  may  be  discovered  by  accident;  evidences  of  mild 
pericementitis  appear,  and  the  pulp  canal  is  opened  to  search  for 
a  cause.  The  pulp  may  be  found  alive;  if  alive,  and  it  is  killed,  or 
if  it  is  found  dead,  broaches  pass  suddenly  into  the  mass  of  soft 
tissue  underlying  the  root.  The  progressive  loosening  of  the  tooth, 
with  its  peculiar  movement,  is  about  the  only  constant  symptom  of 
the  condition. 

In  cases  of  live  pulp  this  organ  may  be  hyperemic  or  inflamed,  so 
that  increased  response  to  heat  or  cold  is  felt  and  there  may  be  the 
reflex  pains  of  pulpitis,  this,  taken  in  connection  with  the  tenderness 


DEGENERATION  OF  THE  PERICEMENTUM  587 

upon  percussion  which  can  usually  be  elicited,  and  \Yith  the  peculiar 
loosening  of  the  tooth,  is  a  diagnostic  guide. 

Flagg^  stated  that  reflex  neuralgias  occur  in  this  condition,  but 
that  the  most  constant  indication  noted  by  him  was  a  sense  of  dis- 
comfort about  the  jaws,  vaguely  associated  with  some  one  tooth. 
The  patient  is  convinced  that  if  the  tooth  were  removed  relief  would 
follow.  In  the  absence  of  the  loosening,  which  may  not  occur  until 
the  root  is  nearly  gone,  the  resorption  is  most  commonly  discovered 
by  entering  the  pulp  canal  and  finding  its  length  much  shortened. 
In  some  cases  the  resorption  may  be  found  near  the  gum  margin  and 
simulating  a  cavity  of  decay,  from  which  it  may  readily  be  diag- 
nosed by  its  appearance  when  exposed  by  packing  the  gum  away. 
Such  cases  appear  to  accompany  a  marginal  gum  resorption.  (See 
page  584.) 

The  a,'-rays  should  exhibit  the  condition  with  sufficient  clearness 
to  fiu-nish  an  absolute  diagnosis.  In  the  case  shown  in  Fig.  514,  the 
cupped  area  does  not  show  in  the  radiograph,  though  the  side  view 
exhibits  it  absolutely. 

Treatment. — If  a  diagnosis  can  be  made,  the  tooth  should  be 
extracted  except  in  the  cases  near  the  gum  margin  alone,  which  may 
be  filled  with  plastic  fillings.    Even  then  the  condition  may  progress. 

DEGENERATION  OF  THE  PERICEMENTUM. 

It  has  been  shown  that  long  before  there  is  any  detachment  of 
cementum  and  overlying  tissues,  such  as  denotes  a  true  periodonto- 
clasia, the  pericementiun  loses  its  histological  characteristics  which 
shows  that  degenerative  changes  have  occurred,  the  normal  fibers 
and  cells  being  replaced  by  tissue,  ill-defined  in  character,  or  in  some 
cases  the  tissue  takes  on  that  characteristic  ill-definition,  so  to  speak, 
known  as  fibroid  degeneration.  Areas  of  degeneration  among  normal 
fibers,  swollen  or  obliterated  fibers,  fatty  degeneration,  endarteritis, 
perivascular  round-celled  infiltration,  general  inflammatory  infiltra- 
tion, fibroid  appearance  of  the  alveolar  bone,  hypercementosis  and 
resorption  of  root  and  bone  are  noted  in  histological  specimens  and  all 
are  natural  consequences  of  non-septic  inflammation.  As  degeneration 
of  any  kind  is  a  retrograde  step  toward  death,  naturally  the  vitality 
of  such  tissue  is  impaired  probably  through  disturbances  of  its  vas- 
cular system.  Therefore,  any  inflammatory  changes  due  to  produc- 
tion of  non-septic  pericementitis  by  any  cause,  leads  to  its  degenera- 
tion and  predisposes  the  tissue  to  invasion  by  liquefying  bacteria  at 

1  Lecture  on  Dental  Therapeutics. 


588  NON-SEPTIC  PERICEMENTITIS 

the  gum  margin.  The  pericementum  lias  occasionally  been  described 
as  "torn  away,"  "melted  down,"  etc.,  but  the  probable  explanation 
is  as  given  above.  Though  almost  evident  this  is  difficult  of  verifica- 
tion, except  by  the  analogy  of  the  progressive  destruction  of  the  peri- 
cementum in  pyorrhea  ah'eolaris  (see  page  569) .  The  above  descrip- 
tion will  fit  the  phenomena  of  the  various  phases  of  tooth  loosening 
and  loss.  Thus,  for  example,  in  a  case  begmning  wath  malocclusion  we 
may  have  the  folio  wig  steps:  (1)  malocclusion;  (2)  non-septic  peri- 
cementitis; (3)  pericemental  degeneration;  (4)  bone  mflammation, 
degeneration,  resorption;  (5)  consequent  looseness  of  tooth  from  lack 
of  support;  (6)  extrusion,  increased  malocclusion  and  further  degen- 
eration from  the  higher  inflammation  due  to  increased  irritation; 
(7)  infection  at  gum  margin  inducing  a  purulent  or  non-purulent 
periodontoclasia.  Beginning  in  the  counter  direction  we  have,  for 
example,  (1)  calculus  formation  at  gmn  margin;  (2)  marginal  inflam- 
mation and  infection;  (3)  purulent  or  non-purulent  marginal  peri- 
odontoclasia (pyorrhea  alveolaris);  (3)  aggravation  and  penetration 
into  deeper  pericementum  and  gmn  tissues;  (4)  associated  non-septic 
inflammation  still  deeper;  (5)  resorption  of  alveolar  bone;  (6)  conse- 
quent looseness  of  tooth  and  further  deep  degenerations;  (7)  looseness 
as  a  cause  of  further  inflammation  with  production  of  extrusion 
and  malocclusion  and  thus  worse  effects  of  infection  which  either 
must  be  combated  or  the  tooth  lost. 

It  is  for  this  reason  that  malocclusion  may  be  either  a  cause,  or 
result,  of  pyorrhea  alveolaris. 

The  causes  leading  to  non-septic  pericementitis  may  any  of  them 
produce  pericemental  degeneration  if  long  continued.  Those  acute 
conditions  just  previously  described  are  more  apt  to  demand  a  prompt 
cure  usually  given  while  more  chronic  causes,  such  as  overuse,  abuse, 
non-use  and  malocclusion  of  teeth  are  the  usual  forerumiers  of  the 
profound  pericemental  degenerations  which  ordinarily  are  not  com- 
plained of  until  profound.  In  view  of  applied  therapeutics  they 
should  be  considered  separately. 

OVERUSE  OF  TEETH. 

By  overuse  of  a  tooth  is  meant  such  a  variety  of  occlusion  that  the 
tooth  receives  a  greater  stress  than  its  neighbors,  or  than  it  is  designed 
to  bear,  or  the  subjection  of  the  tooth  to  unusual  work.  The  stress 
may  be  received  in  the  normal  direction,  but  be  excessive  in  amount. 
The  most  prominent  cause  of  this  condition  is  the  loss  of  one  or  more 
other  teeth,  permitting  undue  stress  to  fall  upon  the  neighboring 
teeth,  or,  in  some  cases,  on  far -distant  teeth.    The  tipping  of  extracted 


OVERUSE  OF  TEETH 


589 


teeth  puts  them  m  malocclusion.  Too  prominent  artificial  crowns, 
particularly  those  of  the  all-gold  type,  cause  a  general  increase  of 
stress  upon  the  pericementum.  Enormously  overfull  contoiu-  fillings 
may  establish  a  similar  condition.  Lack  of  firm  approximal  contact 
lessens  mesial  and  distal  support  and  ordinary  use  becomes  over- 
working. When  but  few  isolated  teeth  remain  m  one  denture  and 
have  antagonists,  the  teeth  are  certain  to  be  overworked.  Isolated 
and  other  teeth  to  which  are  attached  clasps  of  artificial  dentures  or 
too  large  pieces  of  bridge-work,  are  in  the  majority  of  cases  being 
constantlv  overstrained. 


Fig.  568 


Fig.  569 


Periodontoclisis  due  to  overwork. 


Apical  bone  resorption  due  to  overuse 
and  looseness  ■without  discoverable  peri- 
dontoclasia. 


There  is  a  disposition  to  regard  teeth  as  incapable  of  holding  fixed 
bridge-work  or  at  least  of  being  normal  in  a  fixed  position  when  at 
work  as  is  the  case  either  with  fixed  or  the  usual  t\^e  of  removable 
bridge.  As  opposed  to  this  the  retention  of  normal  individual  mo^■e- 
ment  of  teeth  by  construction  of  removable  bridges  designed  to  per- 
mit it,  is  advocated.  While  the  latter  has  yet  to  be  demonstrated 
over  a  long  period  of  years,  it  may  be  stated  that  the  former  when 
constructed  upon  sufficiently  strong  piers  to  begin  with  and  hygienic 
conditions  maintained  has  prevented  far  more  looseness  than  caused  it 
and  been  satisfactory  for  many  years.  Even  in  pyorrhea  of  moderate 
extent  it  "splints"  teeth  so  as  to  prevent  that  mobility  so  destructive 
of  bony  support,  on  the  other  hand  bridge-work  has  been  placed  upon 
teeth  utterly  unsuited  to  the  stress  or  upon  improperly  treated  roots, 
with  disastrous  results  explainable  by  the  description  of  pericemental 
degeneration  above  given  or  resulting  apical  infec:ion.  These  cases 
merely  illustrate  bad  judgment  rather  than  the  faults  of  fixed  bridge- 
w^ork  as  to  pericemental  strain  whatever  other  faults  it  may  have. 

Pathology. — Like  any  other  functional  part  which  is  overworked, 
the  pericementum  is  first  stimulated,  causing  the  vessels  to  dilate. 
Soon  evidences  of  overwork  appear,  and  the  condition  passes  into 


590  NON-SEPTIC  PERICEMENTITIS 

one  of  interstitial  pericementitis;  the  tooth  projects,  and  is  loosened; 
the  overlying  gum  deepens  in  color,  and  evidences  of  venous  engorge- 
ment are  common  (interstitial  gingivitis).  The  result  of  the  con- 
dition is  a  softening  and  degeneration  of  the  substance  of  the  peri- 
cementum; the  alveolar  wall  is  involved  in  the  degeneration,  and  it 
is  resorbed  to  a  greater  or  less  extent.  Cases  have  been  seen 
at  this  point  with  the  gum  margins  as  perfect  as  in  any  normal 
tooth  though  a  s;^inmetrical  resorption  of  margins  may  be  present. 
In  one  marked  case  in  which  incisors  met  with  a  slight  lingual 

Fig.  570 


Illustrating  use  of  overarch  bar.     See  text.     (Gorman.^ 

occlusion  upon  the  lowers,  forcing  them  labially,  the  teeth  were 
as  loose  as  in  the  average  pyorrhea  case,  but  the  gum  margins 
showed  absolutely  no  pocket.  At  any  stage  of  the  disturbance 
marginal  infection  may  occur,  and  the  degeneration  and  destruc- 
tion of  the  pericementum  be  hastened  by  suppuration  or  other 
secondary  degenerations  establishing  pyorrhea  alveolaris. 
The  symptoms,  diagnosis,  and  clinical  history  are  given  in  the 

'  Items'of  Interest,  October,  X913. 


OVERUSE  OF  TEETH 


591 


above  descriptions.  The  prognosis  is  the  inevitable  loss  of  the  tooth 
if  the  causes  be  not  removed,  in  which  event  the  prognosis  is  governed 
by  the  extent  to  which  the  degeneration  has  proceeded.  (See 
Interstitial  Gingivitis.)  These  cases  are  often  seen  at  a  time  when 
it  is  difficult  to  say  which  came  first,  the  pyorrhea  or  the  overwork, 
but  the  conditions  of  evident  overstrain,  noted  over  a  period  of  years 
in  the  same  patient  without  actual  gum  pockets,  as  when  posterior 
occlusion  is  largely  lost,  and  the  usually  prompt  response  to  surgical 
rest  lead  to  inference  that  overwork  started  the  predisposition  to 
pyorrhea  in  the  actual  pocket  cases.  Nevertheless  in  pyorrhea  when 
the  marginal  inflammation  has  caused  bone  resorption  to  the  point 
of  tooth  loosening  the  mechanical  strain  of  occlusion  is  a  cause  of 
further  overstrain  and  looseness. 


Fig.  571 

ff777  ^>  1 

^^^^Hv  / 

■^^'M 

^^V^^ 

^^^Hhbbb^'-^x                                    ^^^SSBBSt^^^^^^^M 

^B' 

^m^m^ 

A  case  of  pyorrhea  alveolaris  and  overwork.  Five  natural  and  one  artificial  tooth 
mutually  supported  by  holding  against  plate  brace.  Note  restraint  of  right  cuspid 
and  central  by  clasp,  artificial  tooth  bevels  and  T  button  and  restraint  of  left  teeth 
by  clasp  and  button.  This  principle  may  be  employed  in  ordinary  plate  work.  Adap- 
tation made  by  burnishing  thin  pure  metal  to  teeth  model,  and  stiffening  with  solder. 
This  work  lasted  seven  years  during  which  the  patient  was  not  seen.  Upon  return  one 
tooth  was  found  to  have  been  out  for  some  time  and  the  general  condition  of  the 
mouth  required  several  extractions,  a  plate  was  substituted.  Had  the  patient  been 
regular,  I  believe  this  could  have  been  extended  a  long  time. 

Treatment. — The  teeth,  if  in  overocclusion,  should  be  dressed  off  until 
properly  occluded.  Prosthetic  appliances  should  not  be  so  attached 
by  clasps  as  to  unduly  move  the  clasp  teeth,  especially  buccolingually. 
The  U-clasps  or  movable  clasps  are  worthy  of  consideration  in  this 
regard.    The  appliance  should  support  the  teeth  laterally,  if  possible, 


592  NON-SEPTIC  PERICEMENTITIS 

and  occasionally  the  enclosure  of  the  teeth  by  the  plate  clasps,  with  the 
hooks  facing  each  other  or  a  buccal  embracing  wire  stay,  is  required, 
as,  for  example,  where  four  lower  bicuspids  only  are  retained  for 
support  to  the  plate,  yet  where  they  also  require  support  (Fig.  589). 
Where  incisors  are  loose  yet  teeth  must  be  inserted  on  plates,  the 
judicious  shaping  of  the  natural  and  artificial  teeth  so  as  to  afford  a 
restraint  of  the  natiu-al  ones  against  the  plate  festoon  is  useful  (Fig. 
571).  In  some  cases  the  festoon  of  a  plate  causes  gingivitis  and  tends 
to  cause  loosening.  This  may  be  due  to  an  improper  looseness  of  the 
clasps  permitting  a  rise  and  fall  of  the  plate,  or  the  inner  edge  of  the 
festoon  requires  trimming.  (A  lower  bar  plate  in  which  no  contact 
except  at  clasp  teeth  is  allowed  because  the  bar  lies  beneath  the  tongue 
level  and,  of  course,  away  from  the  teeth  is  an  example  of  the  principle 
involved  in  avoiding  this  class  of  mjury.)  No  attempt  is  made,  how- 
ever, to  cause  the  artificial  teeth  to  strike  before  the  natural  teeth,  in 
the  hope  of  giving  surgical  rest  to  these  organs.  Such  attempts 
always  result  in  failure,  as  they  cause  injuries  to  the  tissues  upon 
which  the  plate  and  teeth  rest,  which  are  more  severe  than  the 
pericemental  disturbance.  Another  fault  in  partial  plate  work  is  the 
embedding  of  the  plate  in  the  soft  tissues  so  as  to  cause  the  artificial 
teeth  to  be  drawn  or  pushed  away  from  occlusion.  Resetting  the 
teeth  on  the  same  base  if  possible  is  a  remedy  and  allowing  slightly 
for  the  contingency  is  a  fair  precaution  against  it.  If  it  occur,  it 
defeats  the  object  of  the  plate  which  is  to  take  strain  from  natural 
teeth  by  dividing  the  work.  Occasionally  the  t;^^e  of  clasp  known  in 
general  as  the  Bonwill  or  Steadman  having  an  occlusal  lug,  is  used  to 
prevent  "sinkage." 

Properly  adjusted  bridge-work  frequently  does  good  service  in 
these  cases,  provided  the  overoccluding  tooth  or  teeth  be  first  dressed 
down  short  of  occlusion  and  are  given  a  period  of  rest  until  the 
pericementum  recovers.  The  bridge,  if  carefully  planned,  may  be 
made  to  direct  and  control  the  stress  received  by  the  injured  teeth. 
Joining  the  various  bridges  is  useful.  In  this  connection  what  is 
termed  the  "  overarch  bar"  is  a  valuable  device.  The  wire  crossing 
the  palate  or  passing  around  teeth  from  one  bridge  to  another  on  the 
opposite  side  automatically  throws  some  of  the  stress  received  by  the 
diseased  teeth  upon  teeth  upon  the  other  side  of  the  arch,  which 
naturally  are  forced  in  an  opposite  direction  during  mastication  or 
at  least  lend  their  support.     Fig.  570  illustrates  this. 

The  use  of  the  Gilmore  attachment  is  useful,  the  wire  supporting 
the  plate  connects  several  teeth  roots  and  gives  them  mutual  support 
as  well  as  attaches  the  plate.  Some  of  these  devices  permit  "rocking" 
unless  care  is  used  to  have  the  giun  tissues  compressed  by  the  plate 


MALOCCLUSION  OF  THE  TEETH  593 

before  the  "sinkage"  is  limited  by  the  device.  This  rocking  means  a 
deadly  stress  upon  the  teeth  to  which  it  is  attached. 

Improperly  occluding  artificial  crowns  should  have  this  fault  cor- 
rected by  removing  the  excess  of  material  or  by  setting  properly 
made  crowns.  All  crowns  should  have  full  mesial  and  distal  contact, 
as  spaces  permit  a  wedging  of  teeth  and  injury  of  the  interdental 
gum  septum,  as  well  as  allow  movement  to  occur. 

Overfull  fillings  should  be  reduced  to  correct  proportions  and 
shape  and  those  lacking  contour  be  built  out.  The  use  of  the  small 
overlapping  pin  described  on  page  611  is  useful  in  conjunction  at 
times. 

Surgical  rest  is  the  only  hope  of  saving  the  tooth. 

MALOCCLUSION  OF  THE  TEETH. 

Each  tooth  of  a  denture  is  not  only  designed  to  receive  a  definite 
amount  of  force,  but  to  receive  it  in  a  particular  direction  or  direc- 
tions; any  excess  of  this  force,  or  alteration  of  its  direction,  is  followed 
by  abnormal  stimulation  of  the  pericementum  and  by  its  overstrain- 
ing. The  effects  following  a  general  increase  of  stress  have  been 
considered  under  the  previous  heading.  By  malocclusion  is  here 
meant  the  constant  reception  of  stress  by  the  pericementum  in 
directions  to  which  it  is  quite  unaccustomed,  or  which  are  not  in 
accordance  with  the  anatomical  design  of  the  tooth.  It  is  a  peculiar 
form  of  overuse. 

Causes. — Original  malpositions  of  the  teeth  may  cause  their  faulty 
occlusion  usually  less  troublesome  as  such  than  as  sources  of  uncleanli- 
ness  and  gingivitis,  etc.  The  most  prolific  som-ce  of  the  condition  is, 
however,  altered  occlusion  due  to  those  changes  of  position  of  the 
teeth  which  follow  upon  the  loss  of  adjoining  teeth. 

Artificial  crowns,  which  do  not  occlude  in  correspondence  with 
the  other  teeth  are  a  common  cause.  Overfull  fillings  or  those  lacking 
in  contour  are  another  cause. 

The  shifting  of  positions  of  the  teeth,  in  consequence  of  patho- 
logical changes  occurring  in  or  about  the  pericementum,  causes  the 
crowns  of  teeth  to  occlude  improperly. 

Pathology. — The  conditions  established  are  those  of  overuse  in  a 
milder  and  more  insidious  manner.  A  typical  example  of  this  condi- 
tion is  that  of  a  lower  second  molar  which  has  gradually  tilted  forward 
in  consequence  of  the  loss  of  the  first  molar;  or  a  central  incisor  which 
has  altered  its  position  in  consequence  of  inflammation  in  or  about 
the  pericementum.  Some  portion  of  the  tooth,  an  edge,  which  before 
did  not  occlude  with  an  antagonizing  tooth,  is  brought  into  occlu- 
38  . 


594  NON-SEPTIC  PERICEMENTITIS 

sion;  if  the  occlusion  be  not  unduly  forcible,  no  immediate  degenera- 
tive changes  are  evident.  If  the  occlusion  be  excessive,  the  peri- 
cementum is  not  uniformly  affected,  but  the  greatest  stress  is  brought 
to  bear  upon  some  lateral  aspect  of  the  structure.  It  responds 
in  the  degree  of  the  overwork,  and  inflammation  and  degenerative 
changes  occur,  which,  if  the  active  causes  be  not  removed,  gradually 
spread  to  other  portions  of  the  pericementum,  and  the  phenomena 
noted  in  connection  with  overuse  occur,  but  are  not  so  general  in 
distribution.  The  tooth  becomes  more  movable  in  one  or  more 
directions — i.  e.,  is  loosened;  it  may  develop  some  degree  of  tender- 
ness upon  percussion,  and  the  gum  color  toward  the  affected  side 
deepens,  although  it  may  remain  normal  in  other  parts.  As  in  the 
previous  cases,  infection  may — indeed,  is  likely  to — occur.  In 
some  cases  the  pericementum  may  degenerate  and  be  destroyed 
about  one  root  of  a  multirooted  tooth,  and  remain  about  the  other. 
It  is  to  be  remembered  that  a  less  degree  of  irritation  may  produce 
hypercementosis. 

Pyorrhea  alveolaris  in  any  form  is  a  localized  suppurative  peri- 
cemental inflammation,  which  causes  inflammation  of  the  peri- 
cementum in  general.  Swelling  occurs  and  the  tooth  is  pushed  up 
into  malocclusion.  Other  teeth  are  sometimes  urged  out  of  occlu- 
sion by  these.  Such  teeth  may  sometimes  be  dressed  off  one  thirty- 
second  of  an  inch  before  the  overocclusion  is  relieved.  A  direct 
result  of  the  strain  and  compression  brought  to  bear  upon  apical 
tissue  is  the  production  of  non-septic  pulpitis  with  reflex  pain  and 
response  to  heat  and  cold  (see  Fig.  355). 

Diagnosis  and  Treatment. — In  all  malposed  teeth  a  careful  examina- 
tion should  be  made  of  their  mode  of  occlusion.  If  the  tooth  exhibit 
tenderness  and  looseness,  malocclusion  is  almost  a  certainty;  it  only 
remains  to  determine  its  direction.  Placing  the  finger  on  the  teeth 
while  the  patient  occludes  the  impact  is  noted  in  marked  cases ;  as  in 
pyorrhea  a  distinct  buckling  may  be  felt. 

The  spots  of  faulty  occlusion  may  be  determined  by  placing  a 
strip  of  carbon  paper  (articulating  paper)  over  the  tips  of  the  antag- 
onizing teeth  and  having  the  patient  bite;  the  spots  of  contact  should 
then  be  ground  away  until  the  tooth  is  slightly  short  of  direct  occlu- 
sion. Fresh  strips  of  paper  are  used,  and  the  jaws  moved  laterally, 
as  in  mastication,  to  note  other  points  of  contact;  these  should  also 
be  ground  away  and  the  surface  polished. 

It  suffices  in  some  acute  cases  to  place  a  rubber  dam  or  metal  cap 
guard  upon  a  nearby  tooth  for  a  day  or  two  to  prevent  occlusion 
upon  the  sore  tooth,  which  regains  its  normal  position  in  the  alveolus 
as  the  inflammation  subsides.     The  grinding  and  guarding  may  be 


DISUSE  OF  TEETH  595 

combined,  judgment  being  required.  With  the  loose  teeth,  fixation 
is  the  best  principle. 

Prognosis. — If  the  condition  be  not  corrected  every  time  occasion 
requires,  the  degeneration  progresses  until  the  tooth  is  lost. 

If  marginal  infection  has  occurred,  purulent  or  non-purulent 
marginal  pericemental  liquefaction  (pyorrhea  alveolaris)  may  have 
to  be  considered. 

DISUSE  OF  TEETH. 

Definition. — By  disuse  of  teeth  is  meant  a  degree  of  usage  less  than 
the  amount  which  the  forms  and  structure  of  the  teeth  and  contiguous 
parts  fit  them  for.  The  disuse  may  be  absolute  or  relative;  teeth 
ma}^  not  occlude  at  all,  owing  to  the  loss  of  antagonists  or  to  extremely 
irregular  positions. 

Partial  Disuse. — Causes  and  Pathology. — If  soft  food  be  used 
instead  of  that  requiring  vigorous  mastication,  or  if  one  tooth  of  a 
side  be  diseased  so  that  that  side  of  the  mouth  is  unused  in  mastica- 
tion, or  if  one  of  the  antagonists  of  a  tooth  be  lost,  the  pericementi 
of  the  teeth  involved  do  not  receive  their  proper  amount  of  exercise, 
and  a  degree  of  atony  ensues. 

This  partial  disuse  has  a  more  distinct  relation  to  the  health  of  the 
gum  margin,  which  does  not  receive  a  normal  amount  of  friction 
from  mastication,  and  if  this  be  not  offset,  in  part,  by  prophylaxis, 
marginal  gingivitis  ensues.  As  a  rule  partial  disuse  signifies  a  form 
of  malocclusion  and  though  the  used  portion  may  not  be  in  over- 
occlusion  there  may  result  change  in  position  of  the  teeth  especially 
if  an  extraction  space  exists. 

Infection  and  the  formation  of  calculus  increase  the  irritation  to  a 
marginal  gum  inflammation,  which  is  liable  to  run  into  a  pyorrhea 
alveolaris.     This  is  the  real  significance  of  disuse  as  a  cause. 

Diagnosis  and  Prognosis. — ^A  diagnosis  of  disuse  (relative)  is  usually 
made  out  by  inquiring  as  to  the  food  habit  of  individuals.  It  is 
excessively  common  in  civilized  communities,  particularly  among 
the  well-to-do. 

Treatment. — Patients  should  be  instructed  to  use  the  teeth  for 
chewing.  Prophylaxis  should  be  instituted  and  if  the  cure  will  be  of 
advantage  and  not  worse  than  the  condition,  the  occlusion  should 
be  corrected.  The  considerations  are  then  purely  mechanical.  In 
the  making  of  fillings,  cro'^ns,  etc.,  the  possibility  of  inducing  a  partial 
disuse  must  be  considered  and  avoided,  though  even  here  the  avoid- 
ance of  fracture  is  at  times  to  have  first  consideration,  especially  if  a 
major  portion  of  the  occlusal  can  be  left  in  good  occlusion. 


596  NON-SEPTIC  PERICEMENTITIS 

Absolute  Disuse. — Teeth  which  perform  no  work  directly  in  masti- 
cation, or  indirectly  by  serving  as  abutments  for  a  bridge-piece, 
may  be  said  to  be  in  a  condition  of  absolute  disuse. 

Results. — A  tooth  or  root  whose  pericementum  receives  no  stimulus 
becomes  relatively  a  foreign  body  to  the  organism  and  is  finally  lost 
through  a  series  of  pathological  changes.  (1)  It  is  possible  that  the 
impact  of  blood-pressure  raises  the  tooth  an  infinitesimal  distance. 
and  being  without  antagonism  it  does  not  wholly  recover  its  nor- 
mal position,  the  aggregate  of  these  infinitesimal  differentials  being 
expressed  in  protrusions.  (2)  Possibly  lack  of  accustomed  pressure 
allows  a  slight  hyperemia,  consequent  swelling  and  accompanying 
protrusion  not  compensated  for  by  occlusal  pressure.  Devitalization 
of  the  pulp  sometimes  lessens  this,  but  is  not  advisable. 

This  is  at  times  a  fairly  rapid  process,  and  occurs  often  after  the 
trimming  of  teeth  for  bridge-work  so  as  to  interfere  with  the  planned 
occlusion,  unless  the  bridge  be  rapidly  made.  If  unopposed,  it 
extends  progressively,  the  neck  being  usually  exposed,  though  some- 
times the  alveolar  process  becomes  developed  and  lies  on  a  lower 
level  as  though  it  had  followed  the  tooth  down.  (It  is  hypertrophied.) 
Usually  the  bifurcation  of  a  molar  becomes  exposed,  calculi  form,  and 
the  extrusion  becomes  hastened  by  marginal  gingivitis.  The  tooth 
may  be  firm  even  though  half  its  root  length  be  exposed,  though  often 
it  becomes  looser  than  normal.  Sometimes  it  strikes  other  teeth  with 
a  glancing  motion.  If  the  teeth  in  Fig.  572  were  closer  this  would 
occur,  and  such  a  process  (malocclusion)  hastens  the  loosening.  The 
opposite  gmn  may  be  injured  by  such  a  tooth.  Another  effect  is  the 
wedging  of  food  between  the  teeth  owing  to  a  favoring  entrance,  the 
laterally  unsupported  tooth  wedging  away  and  then  closing  upon  the 
food.    This  injures  the  gum  septum.     (See  Gingivitis,  Fig.  578). 

Finally  the  loosening  or  the  annoyance  compels  the  removal  of 
the  tooth. 

The  danger  of  marginal  infection  is  always  great  in  these  cases. 
Some  degree  of  infection,  no  doubt,  exists  in  all  of  them,  which 
serves  to  explain  the  increased  rapidity  of  the  degenerations. 

Prognosis. — If  teeth  can  be  directly  or  indirectly  brought  into  use, 
so  that  their  pericementi  receive  exercise,  the  cases  may  recover, 
provided  the  teeth  are  not  loose  and  not  too  little  root  implantation 
remains.  If  loose  their  pericementi  are  degenerated  and  swollen 
and  any  excess  work  causes  their  loss  so  they  should  not  have  been 
used  for  bridge  work. 

Treatment. — The  treatment  consists  in  bringing  the  teeth  into  use, 
if  the  degeneration  has  not  proceeded  too  far.  In  crowning  for  a 
bridge  pier  it  is  customary  to  shorten  the  crown  to  the  general  occlusal 


FIBROID  DEGENERATION  OF  THE  PERICEMENTUM      597 

level,  though  even  if  a  little  longer  and  not  in  direct  occlusion  the 
tooth  is  brought  into  a  sort  of  mastication  which  is  useful  if  it  does 
not  introduce  an  element  of  malocclusion,  i.  e.,  if  the  distal  or  repelling 
strain  upon  its  mesial  slope  is  compensated  for  by  the  mesial  strain 
upon  a  pier  or  piers  more  mesial  to  it,  or  upon  a  pontic  tooth,  for 
example,  upon  the  cuspid  of  Fig.  572,  or  pontic  bicuspid  occluding 
with  the  mesial  slope  of  the  lower  first  molar.     In  such  a  case  as  this 

Fig.  572 


Absolute  disuse  and  elongation  of  an  upper  and  a  lower  molar;  partial  disuse  of 
bicuspid;  small  abscess  ca\aty  in  the  bone  about  a  root.  (Philadelphia  Dental 
College  Museum.) 

grinding  both  the  upper  and  lower  molar  occlusally  and  the  intro- 
duction of  an  upper  bridge  is  indicated.  Later,  extraction  is  inevit- 
able. The  operation,  when  determined  upon,  should  not  be  delayed, 
for  not  only  are  bacterial  growths  invited  about  the  loosened  tooth, 
but  the  soft  tissues  are  frequently  increased  in  volume,  and  if  extrac- 
tion be  delayed  until  complete  local  atrophy  of  the  alveolar  walls 
has  taken  place,  a  soft  and  spongy  mass  remains,  which  interferes 
with  the  comfortable  wearing  of  prosthetic  appliances  in  the  future. 

FIBROID  DEGENERATION  OF  THE  PERICEMENTUM. 

Fibroid  degeneration  of  the  pericementum  is  a  senile  atrophic 
change  occurring  in  teeth,  the  pericementi  of  which  have  run  a 
healthy  life  course,  but  finally  have  become  subject  to  senile  marantic 
constitutional  changes  of  not  clear  nature.  The  condition  thus  first 
defined  by  Hopewell-Smith^  is  further  described  as  found  in  that 

1  Dental  Cosmos,  1904. 


Fig.  573 


\....A 


-   C 


Fibroid   degeneration  of  the  pericementum:      C,  cementum;    A,  alveolus;     F,  fibers 
with  decrepit  nuclei.    Transverse  section.     (Hopewell-Smith.) 

Fig.  574 


H 


-  M 


Fibroid  degeneration  of  the  pericementum:     C,  cementum;    M,  degenerated  peri- 
cementum;   A,  alveolus;    H,  enlarged  (osteoporous)  Haversian  canals.     Transverse 
section.     (Hopewell-Smith.) 
(598) 


ACCIDENTS  TO  TEETH  599 

class  of  teeth  of  the  aged  which  have  resorbed  alveolar  margins  and 
exposed  cementum,  but  not  necessarily  subject  to  pyorrhea  alveo- 
laris,  though  traumatic  pericementitis  may  be  present.  In  some 
cases  the  teeth  may  be  firm. 

Pathohistology. — The  chief  characteristics  are  an  increase  in  size 
of  the  fibers  of  the  pericementum,  the  loss  of  their  nuclei,  their 
generally  structureless  character,  and  their  arrangement  in  promi- 
nent bundles  about  large  spaces  (areolae).     (See  Fig.  573.) 

The  fibers  are  firmly  implanted  in  both  bone  and  cementum.  The 
cementum  does  not  become  hyperplastic  (hypercementosed),  but 
the  bone  becomes  osteoporous  and  the  Haversian  canals  contain  a 
shrunken  fibroid  tissue  resembling  that  in  the  pericementum  (Fig. 
574). 

The  gum  tissue  in  the  vicinity  also  undergoes  retrogressive  changes 
in  sympathy,  becomes  less  vascular  and  more  fibroid. 

The  condition  may  persist  without  inflammatory  or  suppurative 
changes,  though  it  may  act  as  a  cause  of  obscure  neuralgia  or  as  a 
predisposing  cause  to  pyorrhea  alveolaris. 

Hopewell-Smith  points  out  that  the  areolar  spaces  ma;y'  admit 
microorganisms  to  deep  parts,  thus  predisposing  to  antral  disease  or, 
possibly,  osteomyelitis.     (See  Marginal  Atrophy  of  Gum.) 

Treatment.— There  is  no  treatment  possible  beyond  that  for  any 
associated  condition  or  extraction  if  it  be  a  cause  of  pain. 


ACCIDENTS  TO  TEETH. 

Apart  from  fracture  of  the  teeth  by  accident,  several  interesting 
accidental  conditions  involving  therapeutics  require  consideration. 

Teeth  Driven  into  Alveolar  Process.^ — Blows,  falls,  etc.,  have  occa- 
sionally caused  teeth  to  be  driven  forcibly  into  the  jaw.  The  condi- 
tion may  be  complicated  by  fracture,  in  which  case  the  judgment 
of  the  operator  must  be  exercised.  If  the  tooth  be  not  fractured 
it  may  be  drawn  down  with  forceps  and  ligated  in  place  until  firm. 
The  use  of  zinc  phosphate  upon  the  ligatures,  if  possible  to  use  it, 
renders  them  more  rigid.  Splints  may  be  used.  If  evidence  of  pulp 
death  be  noted  by  subsequent  test,  or  apical  pericemental  inflam- 
mation, the  pulp  should  be  removed. 

Luxation  or  Partial  Dislocation  by  Accident. — Teeth  may  be  par- 
tially knocked  out  and  driven  either  lingually  or  buccally.  The  pulp 
connections  will  be  ruptured,  as  a  rule,  but  after  asepsis  of  the  parts 
by  means  of  antiseptic  sprays  the  teeth  may  be  pressed  into  place, 
and  if  ligated  or  splinted  may  again  become  firm  by  deposition  of 


600  NON-SEPTIC  PERICEMENTITIS 

bone  about  them.  The  pulps  nearly  always  give  evidence  of  death 
so  that  they  should  be  later  replaced  by  canal  fillings. 

Mendel  Joseph  and  Dassonville^  record  experiments  on  dogs 
showing  a  vital  attachment  of  the  pulp  of  an  immediately  replanted 
tooth.     They  used  strictly  aseptic  precautions. 

Occasionally  evidences  of  reattachment  of  pulp  have  been  recorded^ 
even  after  total  displacement.  (See  page  367.)  If  the  accident  result 
in  elongation  of  the  tooth  with  production  of  a  chronically  spongy 
pericementum,  the  operation  of  replantation  should  be  performed. 

Total  Dislocation  of  Teeth  by  Accident — If  the  accident  or  a  mal- 
advertence  in  extracting  another  tooth  result  in  total  displacement 
from  the  mouth,  the  tooth  or  teeth  may  be  prepared  as  for  replanta- 
tion (see  Plantation),  and  under  aseptic  precautions  replanted  in  their 
alveoli.  If  held  by  ligatures  or  splints  they  will  usually  become  firm. 
If  the  teeth  are  kept  moist  in  a  mild  antiseptic  a  short  delay  if  neces- 
sary does  not  prevent  success,  though  clot  and  granulations  must  be 
swept  out.  The  moisture  also  prevents  the  bleaching  due  to  dryness 
which  is  usually  fatal  to  good  color. 

Attachment  of  Teeth. — Two  or  more  teeth  may  be  attached  by  the 
intervening  alveolar  process,  fracture  of  which  may  cause  both  teeth 
to  be  removed  in  extraction.  In  a  few  cases  of  loose  deciduous  teeth 
the  gum  has  been  sufficient  attachment  to  cause  the  removal  of  two 
teeth  at  once. 

In  some  cases  the  tough,  fibrous  nature  of  the  pericementum 
causes  the  alveolar  bone  fractured  by  the  leverage  upon  it  to  remain 
attached  to  the  tooth,  and  Fig.  168  illustrates  teeth  attached  by 
union  of  pericementum  only. 

Fracture  of  the  Alveolar  Process. — Slight  fractures  of  the  alveolar 
plate  are  of  little  consequence,  as  a  rule.  In  some  cases  one  plate 
may  be  fractured,  and  unless  removed  with  the  tooth,  may  usually 
be  pressed  back  into  place.  Reunion  may  be  looked  for  if  reasonable 
asepsis  be  maintained.  Fractures  of  the  alveolar  process  from  blows, 
kicks,  etc.,  upon  the  jaw  may  become  septic  and  sequestra  may 
form,  necessitating  removal  of  both  bone  and  teeth.  Such  fractures 
should  have  immediate  attention.  The  writer  once  handled  a  delayed 
case  in  which  about  six  plaques  of  alveolar  bone  about  1  x  f  inch  each 
were  bloodlessly  remo\'ed  with  tweezers  after  loosened  teeth  were 
extracted.  They  came  from  both  lingual  and  buccal  sides  of  the  man- 
dible. A  kick  by  a  horse  caused  this  splintering  comminution  of 
alveolar  process  and  body  of  mandible  without  actually  fracturing  the 
jaw  transversely.     The  gums  on  both  lingual  and  buccal  sides  were 

'  L'Odontologie.     See  Dental  Cosmos,  1906,  p.  1060. 
2  Kirk  and  W.  Trueman. 


ACCIDENTS  TO   TEETH  601 

not  especially  affected  nor  was  there  much  suppuration.  Unfortu- 
nately I  was  leaving  for  a  foreign  country  within  a  few  days  and  had 
to  refer  the  case  to  a  hospital  so  have  no  record  of  the  outcome. 
Fractures  of  the  maxillae  should,  of  course,  be  immediately  reduced. 

Hemorrhage  following  Extraction. — Even  in  the  absence  of  hem- 
ophilia postextraction  hemorrhage  may  be  somewhat  severe,  and 
is  well  controlled  by  a  little  tannic  acid  or  powdered  alum  and  thymol 
upon  a  pellet  of  cotton,  or  nosophen  gauze  wet  with  phenolsodique. 

If  necessary  a  linen  compress  should  be  placed  over  it  and  a  Barton 
or  Garretson  bandage  applied.  The  internal  use  of  calcium  chlorid 
or  other  hemostatic  is  indicated  if  the  bleeding  be  continued.  (See 
page  30.) 

Lacerations. ^ — The  tongue,  floor  of  the  mouth,  etc.,  may  be  lacer- 
ated by  the  careless  use  of  forceps,  and  the  lacerated  parts  should 
be  irrigated  with  antiseptics  and  the  mouth  kept  under  astringent 
antiseptics  while  the  parts  are  healing.  Shredded  gum  margins 
should  be  trimmed  up  to  prevent  sloughing. 

Postextraction  Aveolitis.^This  has  been  already  discussed.  (See 
pages  564  and  569.) 

For  ordinary  transient  pain,  phenolcamphor  with  or  without 
menthol  added  or  equal  parts  of  phenolsodique  and  laudanum  are 
useful  applied  on  cotton.  Preparations  of  novocain,  orthoform,  etc. 
are  also  indicated.  Hot  salt  water  held  in  the  mouth  is  analgesic, 
st^-ptic  and  stimulant. 


SECTION  VIII. 

PERICEMENTAL   DISEASES   BEGINNING   AT 
THE   GUM   MARGIN. 


CHAPTER  XIX. 
GINGIVITIS. 

The  diseases  which  begin  at  the  gum  margin  are  all  inflammatory, 
and  are  due  to  mechanical,  chemical,  and  infective  local  irritants, 
and  probably  may  be  due  to  overexcitation  of  the  gum  tissues  by 
leukomains  or  other  toxic  products  which  are  formed  intrinsically 
within  the  body  in  malnutritional  processes,  also  to  overexcitation 
by  certain  drugs,  both  of  which  the  gum  is  endeavoring  to  eliminate. 
(See  S^^llptomatic  Xon-Septic  Pericementitis.)  The  inflammation 
resulting  is  termed  gingivitis.  ^Nlany  mechanical  or  septic  causes 
which  produce  pericementitis,  such  as  overuse  or  apical  abscess, 
finally  induce  an  inflammation  in  the  alveolar  bone  (osteitis),  and 
later  an  inflammation  of  the  gingival  tissue.  In  reverse  order, 
inflammations  beginning  in  the  gum,  reach  the  bone,  and  later  the 
pericementum.  It  is  plain  then  that  pericementitis  and  gingivitis 
are  often  associated,  and  at  the  gum  margin  are  almost  inseparable. 
(See  Fig.  577.) 

If  at  any  stage  of  a  gingivitis  as  is  of  mechanical  or  chemical 
primary  causation,  infection  enter  the  inflammation  becomes  septic. 
If  non-pus-fcrming  organisms  as  the  streptococcus  bre\'is  (salivarius, 
viridans)  a  granulomatous  infective,  chronic  inflammation  may  be 
produced  and  if  pyogenic  bacteria  are  later  established,  pus  is  formed^ 
(pyorrhea  ah'eolaris  of  the  pus  variety).  Some  writers  treat  of  all 
cases  of  gingivitis  as  cases  of  pyorrhea,  advanced  or  incipient,  and 
in  view^  of  the  fact  that  a  simple  gingivitis  may  become  a  pyorrhea 
there  is  some  justification  from  a  preventive  standpoint;  as  Vv-ell  as 
from  the  above  bacteriological  viewpoint;  nevertheless,  there  are 
so  many  phases  of  gingivitis  that  for'  purposes  of  discussion  and 

'  Hartzell  and  Henric;:  Journal  National  Dental  Association,  May,  1917.  p.  492. 
'  •  (603) 


604     PERICEMENTAL  DISEASES  BEGINNING  AT  GUM  MARGIN 

applied  therapeutics  it  is  advisable  to  specify  the  ^^a^iolls  forms  that 
may  exist. 

If  confined  to  the  gum  margin  it  is  properly  designated  marginal 
gingivitis;  if  the  inflammatory  elements  (leukocytes  and  exudates) 
have  infiltrated  the  deeper  connective  tissues  it  may  be  called  deeply 
seated  gingivitis  or  interstitial  gingivitis.  If  a  pus  flow  from  the 
alveolus  accompany  the  deeply  seated  gingivitis  the  condition  of 
pyorrhea  alveolaris  is  established. 

With  any  of  these  conditions  an  hypertrophy  or  an  atrophy  may 
be  associated,  which,  on  the  one  hand,  may  result  in  hypercementosis 
or  exostosis  or  thickening  of  gum,  or,  on  the  other,  in  resorption  of 
gum  or  bone. 

MARGINAL  GINGIVITIS. 

Definition. — By  marginal  gingivitis  is  meant  an  inflammation  con- 
fined to  the  margins  of  the  gums  about  the  necks  of  the  teeth. 

Causes.— The  causes  of  marginal  gingivitis  are  local  and  general, 
which  may  be  subdivided  into  predisposing  and  exciting.  Both 
local  and  general  causes  may  be  in  action  at  the  same  time. 

Local  Causes.^ — The  anatomy  of  the  gum  margin  should  be 
considered. 

Between  the  free  gingival  margin  and  the  enamel  exists  a  space 
considered  normal  (Fig.  577).  As  the  soft  tissue  about  the  teeth  can 
be  distended  by  means  of  oxygen  blown  into  this  space^  (see  also  page 
504)  it  is  evident  that  intercellular  spaces  open  into  it.  Considering 
in  addition  the  presence  of  veins  and  ''glands  of  Black"  it  is  evident 
that  infective  material  entering  the  gingival  space  may  under  mastica- 
tory pressure  (which  in  the  aggregate  is  estimated  by  Hartzell  to 
average  about  a  ton  per  day)  be  forced  into  the  spaces  or  vessels 
to  be  carried  uito  the  pericemental  tract,  which  at  the  gingival  margin 
is  in  close  conjunction  with  the  gingiva  (Fig.  577,  Gg).- 

Doubtless  much  phagocytosis  occurs  protecting  the  gingiva,  but 
when  this  is  inadequate  inflammation  may  occur  from  bacterial 
plaques  on  the  teeth  which  may  generally  be  demonstrated  with 
iodin  disclosing  solutions.  There  is  fm-ther  evidence  in  that  prophy- 
laxis or  plaque  removal  as  a  means  of  cure  succeeds  as  a  rule.  Their 
presence  means  quantitatively,  20  to  600  millions  of  bacteria  to  the 
milligram  (Kligler),  and  qualitatively  streptococci,  staphylococci, 
pneumococci,  spirochetes,  fusiform  bacilli  and  protozoa  (Hartzell, 
loc.  cit.). 

1  Joiirnal  of  National  Dental  Assn.,  1916,  p.  177. 

2  Also  noted  by  Talbot  in  text-book  Intestinal  Gingivitis. 


MARGINAL  GINGIVITIS 
Fig.  575 


605 


!-:;•■_ 

11 

\ 

"1 

u 

;i 

T 

•■'-, 

J. 

X 

-  i 

Diagram  of  glands"of  peridental  membrane.      (Black.)      (Also  called  epithelial 
root  sheath  ot  Hertwig.) 


Fig.  576 


Cm, 


Glands  uf  iiluck.     Epithehal  structures:    Ec,  epithelial  cord,  apparently  showing   a 
lumen;  C'6,  cementoblasts;  Ctw,  cemeptum;  2),  dentin.     (See  Fig.  134.)    (Noyes.) 


Fig.  577 


Longitudinal  section  1 1  j  i  i  uuin  luiiiig  the  gingival  space;  Gg,  gingival  gland 
so-called;  D,  dentin,  A'',  >,at>mj  th's  membrane;  Du,  duct-like  structure  stretcliing 
away  toward  the  gingivals  from  the  epithelial  cord,  seen  at  Ec;  Cm,  cementum, 
separated  from  the  dentin  by  decalicification.  X  50  (about).  The  long  space  next 
to  the  tooth  is  made  by  the  detachment  oi  the  soft  and  band  tissues.  The  space 
between  N  and  Ep  is  the  gingival  space.     (Noyes.) 


MARGINAL  GINGIVITIS  607 

Mechanical  causes  produce  direct  irritation;  these  are  deposits  of 
salivary  calculus  resting  upon  the  gum  or  beneath  the  gum  margin; 
fillings  projecting  beyond  cavity  margin;  the  edge  of  a  bandless 
crown,  the  edges  of  a  poorly  fitted  crown  band  and  the  putrefaction 
of  food,  etc.,  collected  in  the  places  from  which  cement  has  washed 
out;  gum  overlying  cavity  margins  or  edge  of  root  to  which  a  crown 
is  not  adapted  or  of  a  root  with  occlusal  face  under  the  gum ;  bruising 
of  the  gum  margin  by  food  crowded  between  teeth  and  removed 
by  toothpicks;  the  fermentation  of  such  crowded  food. 

The  lack  of  contact  or  too  light  contact  of  approximal  surfaces, 
whether  due  to  faulty  operations  or  induced  by  the  wedging  action 
of  tooth-picks  or  floss  silk,  causing  a  general  non-septic  pericementitis 
and  bone  resorption  (looseness  of  teeth)  are  contributory  to  the 
wedging  of  food. 

The  mechanical  action  of  toothpicks  or  floss  silk  improperly  crowded 
upon  the  gum  margin;  projecting  edges  of  artificial  crowns  or  bits 
of  cement  used  in  their  cementation;  toothbrush  bristles;  fragments 
of  toothpicks,  bones,  or  oyster-shells,  etc. ;  rings  of  rubber  or  of  torn 
rubber  dam  or  ligatures  left  in  position;  rubber  or  tape  wedges 
forced  into  the  gum;  the  crowding  back  of  a  gum  by  ligation 
which  produces  ischemia  for  hours;  improper  contact  of  the  edges 
of  prosthetic  plates  its  clasps  or  other  appliances  about  the  necks  of 
teeth;  injuries  inflicted  by  rubber  dam  clamps,  wedges,  ligatures,  etc.; 
the  eruption  of  teeth  through  the  gums,  bits  of  fractured  alveolar 
bone  undergoing  exfoliation.  Pontic  teeth  may  occasionally  be 
embedded  in  giun  which  has  grown  up  around  them.  It  is  probable 
that  the  movement  of  the  porcelain  against  the  gum  combined  with 
a  possible  sepsis  induces  a  slow  development  of  gum  which  further 
presses  against  the  porcelain.  Inflammation  occurs.  The  vicious 
circle  continues. 

An  interesting  case  of  recurrent  epileptic  attacks  was  proved  due 
to  a  toothbrush  bristle  forced  into  the  gum.^ 

The  action  of  any  of  these  causes  may  be  complicated  through 
the  infection  of  the  mechanically  irritated  part  by  oral  bacteria. 
An  excellent  example  occurred  in  the  editor's  practice.  A  perfect 
gum  margin  was  irritated  by  the  margins  of  a  gutta-percha  cap 
used  as  a  remedy  for  hyperemia  of  the  pulp.  Pyogenic  organisms 
produced  a  marginal  suppuration  which  subsided  upon  removal  of 
the  cap. 

The  pressiu-e  of  plates  into  gum  tissue  either  at  their  edges  or  when 
slight  projections  exist  may  even  cause  superficial  ulceration.     While 

1  Dental  Cosmos,  1910,  p.  594. 


608     PERICEMENTAL  DISEASES  BEGINNING  AT  GUM  MARGIN 

not  marginal  gingivitis  it  illustrates  the  combination  of  mechanical 
and  infective  causes. 

All  forms  of  marginal  gingivitis  are  to  be  considered  as  incipient 
inflammations  which,  let  alone,  may  lead  to  deep-seated  inflammation 
and  tissue  destructions  collectively  called  pyorrhea  alveolaris.  Even 
if  the  causes  of  pyorrhea  are  infective  (see  pyorrhea)  they  act  to  first 
produce  a  marginal  gingivitis. 

Excessive  smoking  and  the  use  of  alcoholic  liquors  produce  local 
irritative  effects,  resulting  in  catarrhal  stomatitis  and  gingivitis. 

Lack  of  exercise  or  brushing  of  the  gums  produces  an  atonic 
condition  of  the  gum  margin,  predisposing  to  gingivitis  of  infective 
character.  Too  persistent  brushing  with  stiff  brushes  may  be 
equally  injurious  by  causing  marginal  irritation. 

A  variety  of  ulcerative  marginal  gingivitis  exists  which  tends  to 
rapidly  penetrate  the  tissues  and  while  it  may  cause  pyorrhea,  usually 
erodes  the  outer  portion  of  the  gum  margin  rather  than  destroys  the 
pericementum  as  in  pyorrhea.  The  gum  margui  has  a  pasty,  slough- 
ing appearance,  and  the  gum  about  several  teeth  may  be  involved. 
Vaughan^  describes  it  as  covered  by  a  grayish  necrotic  covering  which 
when  rubbed  off  leaves  a  sensitive  bleeding  surface,  the  deposit  being 
accumulated  rapidly  in  an  hour  or  two.  He  found  the  bacillus  fusi- 
formis  and  spirillum  which  work  in  symbiosis  in  Vincent's  angina. 
In  the  severe  cases  he  describes  fever,  dysphagia,  headache,  malaise, 
nausea,  marked  salivation,  loss  of  appetite,  increased  cardiac  and 
respiratory  action,  and  glandular  enlargement  as  associate  phenomena. 
It  often  extends  to  the  tonsil  and  may  extend  to  the  lungs.-  Fever 
of  low  grade  is  an  accompaniment.  (See  Vincent's  Angina.)  The 
breath  is  offensive  and  characteristic.  Hinman^  gives  the  following 
bacteriological  technic :  '  'A  smear  is  made  with  a  platinum  loop  from 
ulcerating  surface  to  a  ground  glass  slide,  carefully  fixed  over  the 
flame  of  an  alcohol  lamp,  stained  with  carbol-f uchsin  for  a  few  seconds, 
washed,  stained  with  methylene  blue  for  three  to  fi^'e  minutes,  washed 
and  dried,  examined  for  Vincent's  spirochetes  and  fusiform  bacilli 
which  are  unstained,  being  Gram-negative.  They  usually  appear  in 
large  numbers."  (See  Fig.  580.)  Syphilitic  chancre  may  begin  at  the 
gum  margin,  and  there  is  no  reason  why  aphthie  should  not  be  so 
located  though  usually  elsewhere. 

A  form  of  phagedenic  pericementitis  causing  very  rapid  destruc- 
tion of  the  pericementum  and  loss  of  the  teeth  without  loss  of  alveolar 
wall  has  occasionally  been  noted.     In  one  notable  case  two  upper 

1  Dental  Cosmos.  1912,  p.  651. 
^Hiimian:  Dental  Cosmos,  1916,  p.  1352. 
3  Dental  Cosmos,  December,  1914,  p.  1354. 


MARGINAL  GINGIVITIS  ■    609 

incisors  came  away  three  weeks  after  an  ulceration  appeared  about 
their  gum  margins.  The  patient  wore  the  teeth  for  several  weeks 
in  situ,  and  could  remove  and  reinsert  them  at  will.  The  alveolar 
walls  were  bare,  but  intact.  There  was  but  little  pain.  The  alveoli 
healed  after  removal  of  the  teeth  and  the  freshening  of  the  bone. 
There  was  no  bacterial  examination  made  at  the  time  (1896).  Occa- 
sionally the  gum  margin  on  a  buccal  side  as  a  rule  becomes  invaded 
by  bacteria  and  a  granulomatous  swelling  occurs,  sometimes  this  is 
the  forerunner  of  a  pyorrhea  pocket  and  sometimes  a  distinct  abscess 
occurs  in  the  tissue  of  the  gum  (a  gingival  abscess). 

Cook  has  shown  that  stimulant  and  astringent  washes,  if  used 
to  excess,  have  a  degenerative  influence  upon  the  gum  margin.  A 
too  powerful  formaldehyd  wash  has  the  same  effect. 

The  production  of  deeply  seated  gingivitis  by  causes  of  systemic 
or  drug  origin  involves  a  marginal  gingivitis,  but  marginal  gingivitis 
is  not  always  produced  by  local  causes  of  interstitial  gingivitis;  at 
least,  not  at  first  (see  page  588). 

Systemic  Causes. — These  are  the  same  as  for  Deeply  Seated  Gingi- 
vitis, which  (see  page  616). 

Pathology. — ^The  pathology  of  marginal  gingivitis  is  that  of  an 
inflammation  located  in  a  peculiar  situation — i.  e.,  in  the  marginal 
gum  tissue — and  tending  to  spread  into  the  deeper  interstitial  tissues. 
(See  Pathology  of  Deeply  Seated  Gingivitis.)  As  shown  above 
when  pyogenic  bacteria  enter,  a  pus  flow  or  pyorrhea,  or  in  some  cases 
a  septal  abscess  or  marginal  abscess,  supervenes.  These  conditions 
discussed  above  and  on  page  617. 

Symptoms. — The  symptoms  of  marginal  gingivitis  depend  upon  the 
cause  and  degree  of  inflammatory  action.  When  mechanical 
causes  are  acting  the  gum  presents  an  inflamed  appearance;  it  is 
swollen,  of  a  bright  red  or  purplish  color,  very  sensitive  to  touch, 
and  bleeds  readily,  growing  around  an  irritating  pontic  tooth  it  may 
appear  as  though  the  latter  had  sunken  into  it.  Likewise  it  may 
appear  to  have  grown  up  between  a  plate  festoon  and  a  tooth,  and  at 
times  apparently  be  merely  hypertrophic  rather  than  inflamed. 

If  a  calculus  rest  against  the  gum,  the  latter  may  present  a  raw, 
chronically  inflamed  surface  in  contact  with  it.  A  ragged,  red, 
split  margin  of  gum  is  often  associated  with  calculus  upon  the  labial 
surfaces  of  lower  incisors,  cuspids,  and  bicuspids,  and  upper  cuspids 
and  bicuspids.  At  times  the  lingual  surfaces  of  the  lower  incisors 
present  such  an  appearance.  If  subgingival  calculus  be  present, 
the  gum  margin,  if  markedly  affected,  appears  loosened,  and  is  of 
a  flabby  appearance  and  purplish  in  color.  In  some  cases  the  gum 
margin  appears  thickened  or  hypertrophied. 
39 


610     PERICEMENTAL  DISEASES  BEGINNING  AT  GUM  MARGIN 

A  bloodshot  appearance — i.  e.,  enlargement  of  terminal  vessels — 
is  often  seen  in  gingivitis. 

In  cases  due  to  unhygienic  conditions — i.  e.,  food  collections  or 
vitiated  secretions  about  the  necks  of  teeth — a  raw,  red,  outer 
surface  of  the  gum  margin  is  noted,  particularly  in  young  persons. 

In  stomatitis  ulcerosa  a  yellow,  pasty  ulceration  of  the  gum  mar- 
gins may  occur.  It  is  rodent  in  character,  very  painful,  and  may 
cause  rapid  loss  of  the  pericementum  and  of  the  tooth.  (See  Vincent's 
Angina  and  page  608.)  In  gingivitis  due  to  oral  infection  by  the 
coccus  of  gonorrhea  an  intense  gingival  inflammation  with  looseness 
of  the  teeth,  pyorrhea  alveolaris,  and  profuse  salivation,  may  occur.^ 

Talbot^  describes  a  greenish-gray  glazed  surface  of  ulcerated 
raw  gum  in  two  cases  of  profuse  interstitial  gingivitis  due  to  the 
gonococcus. 

Stein  is  inclined  to  doubt  the  etiology.^ 

Bloodgood*  describes  a  general  ulitis  in  which  the  teeth  may  be 
almost  buried  as  a  concomitant  of  acute  leukemia. 

The  classification  of  the  gingivitis  depends  upon  the  cause  and 
progress  of  the  disease. 

Prognosis. — If  the  case  has  run  an  acute  course  and  is  due  to  the 
action  of  mechanical  causes  plus  infection,  recovery  is  usually  prompt 
upon  the  removal  of  the  cause  and  sterilization  of  the  injured  part. 
In  the  chronic  cases  due  to  the  more  slowly  acting  mechanical  and 
infective  causes  combined — e.  g.,  salivary  calculus  plus  infection 
— much  deeply  seated  gingivitis  may  have  occurred  accompanied 
by  pericemental  and  alveolar  resorption.  This  usually  constitutes 
a  permanent  loss.  If  the  gum  margin  is  in  a  state  of  atony  or  inflam- 
mation as  the  result  of  collections  of  bacteria,  etc.,  upon  the  cervices 
of  the  teeth,  their  condition  may  be  improved  by  frequent  prophy- 
laxis. 

Treatment. — The  treatment  of  the  condition  consists  in  removing 
the  source  of  irritation  and  restoring  the  normal  circulation  in  the 
parts.  If  the  source  of  the  disorder  be  in  some  underlying  constitu- 
tional condition,  the  symptoms  may  be  ameliorated,  although  not 
entirely  cured,  by  the  correction  of  the  general  disorder. 

Cases  due  to  mechanical  irritation  are  commonly  confined  to  one 
or  several  teeth,  rarely  to  an  entire  denture,  except  cases  continued 
in  consequence  of  deposits  of  scaly  calculi  beneath  the  gum  margin 
or  under  plates.     Foreign  bodies,  such  as  bristles  and  fragments  of 

'  Vines.    British  Journal  of  Dental  Sciences,  1903,  and  Dental  Cosmos,  1903. 
«  Dental  Cosmos,  1905. 

2  Bacteriology  in  its  Relationship  to  the  Oral  and  Nasal  Cavities.  Items  of  Interest, 
1914. 

*  Journal  of  National  Dental  Association,  1915,  p.  8, 


MARGINAL  GINGIVITIS 


611 


bone,  should  be  removed.  Projecting  fillings  or  overhanging  crown 
margins  should  be  made  flusli  with  the  general  tooth  surface.  Plates 
permitting  gum  to  develop  between  the  festoon  and  tooth  should 
either  have  material  added  to  a  perfect  fit  or  be  filed  away  to 
remove  the  plate  margin  to  a  distance.  Salivary  calculi  should  be 
removed.  When  food  crowds  upon  gum  margins  [between  teeth, 
lateral  or  mesiodistal  contacts  should  be  established  either  by  con- 
touring filling,  introducing  a  bridge  which  establishes  such  proximal 
contact,  or  in  some  cases  by  wedging  at  some  convenient  point  so 
as  to  crowd  several  teeth  together,  then  introducing  a  contour  filling 
or  inlay.  The  contact  should  exist  just  a  little  to  the  gingival  of  the 
marginal  ridges  and  not  be  too  broad  and  should  be  well  rounded. 


FiQ.  578 

L^           '^ 

^H 

^pr    ^ff^^^fk 

K^ 

^ 

WI^^sMM 

r^w 

r 

^^^^Bm 

■     ■'        -'^fea. 

■    ,ytad 

H^B 

^B             ^^^SmKm 

iSliKiiflHi 

mhh 

^Hb 

^^^^^j^^^B 

issBBSi^pH^^HH 

l^^^^l 

Hh 

liiiHiiiitfHiHB 

■■HH 

Marginal  gingivitis  located  in  septal  tissue  between  upper  second  and  third  molar 
(see  text).  Also  shows  anterior  drifting  of  second  molar,  due  to  extraction  of  first 
molar  early  in  life. 


In  another  phase  of  this  condition  in  the  writer's  own  mouth  the 
extraction  of  a  lower  third  molar  allowed  the  distal  cusp  of  the 
lower  second  molar  to  wedge  between  the  upper  second  and  third 
molars,  so  that  the  third  molar  was  pushed  distally  and  shredded 
food  packed  in  simultaneously  causing  extreme  and  annoying  gingi- 
vitis. In  such  a  case  if  grinding  the  cusps  of  the  antagonizing 
molars  does  not  relieve,  only  extraction  or  firm  attachment  of  the 
third  and  second  molar  will  give  relief  (Fig.  578).  In  a  few  similar 
cases  where  fillings  were  present  the  fillings  have  been  overcontoured 
and  a  clasp  metal  wire  imbedded  in  a  groove  in  one  filling  and  the 
other  pointed  end  allowed  to  rest  in  a  slight  groove  in  'the  adjoining 
filling.  In  this  it  plays  freely  but  prevents  the  crowding  of  food, 
though  food  may  float  in  laterally  without  direct  mjmy.  It  is  highly 
satisfactory  especially  in  short  bites  and  cupped  out  'occlusals  of  filling, 
and  also  where  two  molars  are  unsupported  on  either  side. 


612     PERICEMENTAL  DISEASES  BEGINNING  AT  GUM   MARGIN 


The  technic  is  as  follows:  Cut  a  deep  trench  mesiodistally  in  the 
filling  selected  for  anchorage  and  a  shallower  one  in  the  adjoining 
filling  or,  if  necessary,  grind  a  shallow  polished  groove  in  the  occluso- 
proximal  enamel.  Roughen  the  wire  where  it  is  to  be  imbedded  and 
shape  and  polish  the  projecting  end  with  reference  to  its  bed  and  the 
occlusion.  Line  both  grooves  with  very  soft  amalgam.  Tap  the  wire 
to  a  proper  seating,  cover  with  soft  amalgam  and  harden  by  the 
wafering  process.  Uncover  the  occlusal  of  the  projecting  wire.  When 
the  amalgam  has  fairly  set,  move  the  teeth  apart  sHghtly  to  disturb 
any  amalgamation  of  the  projecting  portion  which  should  play  in  an 
adapted  groove. 

This  condition  frequently  results  when  a  bridge  has  been  inserted 
from  a  second  molar  forward.  The  third  molar  moves  away.  If 
any  looseness  of  teeth  exist  it  may  be  better  to  include  the  third 
molar  as  an  abutment. 

Fig.  579 


Pin  embedded  in  filling  in  third  molar  and  extending  into  a  groove  in  filling  in 
second^molar.     Extension  plays  back  and  forth  but  protects  gum. 

A  further  possibility  lies  in  the  use  of  a  crown  on  the  third  molar 
with  a  hook  or  mortised  piece  attached,  which  hook  or  mortise  plays 
in  a  suitable  pocket  in  the  crown  attached  to  the  bridge,  or  the  pin 
referred  to  may  play  in  a  groove.  Some  cases  of  bridge  work  are 
constructed  with  hook  attachment,  said  hook  playing  in  a  specially 
made  inlay  in  a  tooth  not  otherwise  included  in  the  bridge  (Fig. 
579). 

Any  associate  pyorrhea  due  to  this  cause  is  usually  rapidly  cured 
by  this  establishment  of  contact,  but  may  require  some  treatment. 

Following  mechanical  corrections  perfect  cleansing  of  all  teeth  is 
indicated,  this  to  be  maintained  by  monthly  prophylaxis,  at  least 
until  the  case  is  cured  and  then  continued  periodically  for  prevention. 

In  case  of  h^-pertrophic  ulitis  due  to  and  co^'ering  a  pontic  tooth 
a  mucous  anesthesia  is  done  and  a  semilunar  cut  made  to  carve  off 


MARGINAL  GINGIVITIS  613 

a  piece  of  gum.  The  tooth  is  then  cut  down  with  a  cone-shaped 
Miller  carborundum  stone  and  dressed  smooth  with  abrasi\^e  strips. 

Waas,i  by  careful  test,  has  found  iodm  trichlorin  in  1  to  1000 
aqueous  solution  with  menthol  and  saccharin  added  for  flavor  as 
destroying  malignant  streptococci  and  B.  diphtherise  in  three  minutes. 
It  may  therefore  be  considered  first  if  active  germicidal  work  is  a 
necessity. 

Antiseptic  mouth  washes  should  be  employed  frequently,  no 
matter  what  the  cause.  If  the  gum  tissue  be  soft  and  spongy, 
showing  signs  of  venous  hyperemia,  antiseptic  astringent  mouth 
washes  should  be  freely  used: 

'S^ — Zinc,  chlorid gr.  x 

Aquae  menth.  pip fgj M. 

Increase  as  desired. 

The  above  preparation,  used  in  spray  from  an  atomizer,  or,  if 
diluted,  as  a  wash  several  times  a  day,  is  an  excellent  local  application, 
meeting  both  indications.  Prescriptions  containing  eucalyptus  and 
benzoic  acid  are  excellent: 

^ — Acid,  benzoic 3  parts 

Tinct.  eucalyptus 15  parts 

Ol.  menth.  pip. 1  part 

Alcohol •      .      .        100  parts 

Saccharin ■ 2  parts — M. 

(MUler.) 

The  above  formula  diluted  one-half  is  agreeable  and  efficient. 
Au  alkaline  1  per  cent,  salicylic  acid  wash  is  useful,  not  only  for 
the  gingivitis,  but  any  attendant  fetor  of  breath: 

'Bf — Sodii  boratis giss 

Acidi  salicyUci gr.  xv 

Aquae  menthse  pip fSiij — M. 


^      The  following  is  astringent  and  antiseptic: 


I^ — Boroglycerini, 

Tinct.  krameriae, 
Tinct.  calendulae, 

Alcoholis aa  fgj — M. 

Sig. — One  or  two  teaspoonfuls  to  a  small  glass  of  water. 

Truman  advises  the  use  of  hydronaphthol  in  an  astringent  vehicle 
as  an  effective  germicide  for  use  by  a  patient: 

I^ — Hydronaphthol gr.  x 

Glycerol fgj 

Alcohol fgj 

Aquae  destil fgj — M. 

Sig. — Use  as  a  wash  several  times  a  day.  (Pierce.) 

J  Dental  Items  of  Interest,  March,  1918. 


614     PERICEMENTAL  DISEASES  BEGINNING  AT  GUM  MARGIN 
Talbot  recommends  for  gingivitis  the  following : 

I^ — Zinc  iodid 15  grams 

lodin 25  grams 

Glycerin 50  grams 

Water 10  grams — M. 

Sig. — Apply  to   gum   on  cotton  wound  on  an  applicator  and  dry  after  each 
painting.  (Talbot.i) 

The  -^Ti-iter  has  found  this  applied  as  directed  and  also  diluted  to 
one-fourth  strength  with  water  and  applied  frequently  by  the 
patient  as  a  lotion  or  approximately  1  to  100  as  a  wash  to  be  very 
valuable  in  simple  and  suppm-ative  gingivitis.  It,  however,  causes 
superficial  discoloration  of  the  teeth  and  gives  a  leaden  color  to 
bridge-work  as  does  iodine  in  any  form. 

The  following  is  a  5  per  cent,  formaldehyd  solution  which,  diluted, 
can  be  used  as  a  mouth  wash,  having  astringent  and  antiseptic 
qualities.  It  is  also  useful  in  various  strengths  as  a  germicide  for 
root  canals.     A  formula  for  quantity  is  given,  which  may  be  reduced 

in  prescriptions: 

No.  1 

I^ — Thymol 5iss 

Menthol        . 3ss 

Oil  of  ecucalyptus, 
Oil  of  gaultheria, 
Oil  of  cassia, 

Oil  of  cloves aa    fgiss 

Alcohol f§ij— M. 

No.  2 

Formaldehyd,  40  per  cent,  sol Oj 

Boric  acid, 

Sodium  biborate aa      3iij 

Water Oij— M. 

No.  3 
Water  to gal.  j 

Make  up  No.  1  first  and  shake  well.  Place  No.  2  in  a  gallon 
demijohn  and  shake  well;  add  No.  1  and  shake  again;  add  No.  3 
and  shake  well.  For  dispensing  this  may  be  filtered;  for  office  use 
this  is  not  necessary.  For  mouth  use  one-half  teaspoonful  is  to  be 
diluted  in  two  ounces  of  water,  making  a  1  to  600  formaldehyd 
solution. 

Equal  parts  of  Listerine  and  ordinary  distillate  of  hamamelis  is  a 
useful  combination.  Glycothymolin  is  a  very  popular  proprietary 
mouth  wash.  Lavoris  and  Vernas  Lotions  are  agreeable  zinc  chloride 
washes  when  used  as  directed.  Phenol-sodique,  1  to  7  of  water 
is  quite  useful.     Alcohol  1  vinegar  1  water  8  is  recommended. 

1  Dental  Cosmos,  1905,  p.  1312. 


MARGINAL   GINGIVITIS  615 

For  mercurial  gingivitis  and  stomatitis  the  following  has  been 
rationally  recommended  ■} 

^ — Tinct.  myrrhse  . f  gjjj 

Potassii  chloratis '      ^      '      3ss 

Sodii  chloridi 5ij 

Aqu^dis .'.'.'.■.■      .'q.s.  adfgviij— M. 

t)]g. —  Use  as  mouth  wash.     Repeat  every  two  hours. 

Fig.  580 

/--%., \:f^  {^--^' ",.;'"  :.;  ^^,    %^ 

\    »•• »  --^       r        *~^  ' 

^•■^■^' '■-'■■■/.." 

Showing  Vincent's_bacteria  (the  fine  spiral  forms).     (Lederer.) 

All  mouth  washes  require  an  application  of  about  two  minutes' 
duration  at  least  twice  a  day  after  cleansing  the  teeth  in  order  to 
produce  the  best  effects.    As  this  is  somewhat  fatiguing  to  the  ora. 
muscles,  several  applications  may  be  made,  one  after  the  other 
until  the  total  is  attained  (Fig.  580). 

In  Vincent's  angina  (and  in  all  acute  suppurative  conditions)  I 
have  found  the  following  a  very  active  germicidal  wash: 

'Si — Hydrargyri  bichloridi gr.  j 

Aquae  hydrogenii  dioxidi f  giv M. 

Sig. — Use  several  times  a  day. 

Vaughn^  recommends  silver  nitrate  15  to  30  grains,  water  fgj, 
LugoFs  solution,  chromic  acid  10  per  cent.,  zinc  chlorid  2  per  cent., 
and  argyrol  full  strength.     Lederer  applies  salvarsan  to  the  germs. 

1  Medical  Press,  via  Dental  Cosmos. 

2  Dental  Cosmos,  1912,  p.  655. 


616     PERICEMENTAL  DISEASES  BEGINNING  AT  GUM   MARGIN 

Campbell  and  Dyas/  working  on  129  cases  in  army  service,  use  a 
routine  treatment  of  liquor  potassii  arsenitis  swabbed  on  three  or  four 
times  a  day.  When  ulcers  are  deep  10  per  cent,  silver  nitrate  is 
liberally  applied  and  the  above  routine  employed.  Curettement  is 
sometimes  necessary.  They  use  large  doses  of  liquor  arsenicalis  inter- 
nally, sodium  cacodylate  hj^^odermically  or  salvarsan  (in  cases  of 
general  stomatitis  and  gingivitis)  combined  with  antiseptics  locally 
until  the  case  is  under  sufficient  control  for  the  local  treatment.  The 
cure  is  in  from  four  to  seven  days.  Kirk-  recommends  in  addition 
local  application  of  tincture  of  iodin  and  irrigations  of  hot  water. 
The  glandular  enlargements  require  a  cold  compress  or  the  ice-bag. 
For  the  restoration  of  gum  tissue  between  molars  and  bicuspids 
L.  Ashley  Faught^  has  recommended  applications  of  10  per  cent, 
trichloracetic  acid  on  an  orange-wood  stick  every  day  or  two  until 
the  case  is  cured. 


DEEPLY  SEATED  GINGIVITIS*  (INTERSTITIAL  GINGIVITIS, 

TALBOT). 

Definition. — This  may  be  defined  as  an  inflammation  characterized 
by  the  presence  in  the  deep  connective-tissue  elements  of  the  peri- 
cementum and  gum  tissue  of  an  excessive  number  of  leukocytes, 
attracted  thither  by  a  general  or  local  irritation  of  the  tissue  men- 
tioned. 

Local  Causes. — Any  of  the  local  causes  producing  marginal  gin- 
givitis, if  acting  deeply,  may  produce  a  deeply  seated  gingivitis.  In 
addition  to  these,  the  eruption  of  teeth,  the  wedging  of  them,  or 
their  movement  in  orthodontia,  the  overuse,  malocclusion,  or  dis- 
use, in  short,  any  of  the  causes  of  pericementitis,  septic  or  non- 
septic,  if  producing  inflammation  extending  beyond  the  confines  of 
the  pericementum,  are  causes  of  deeply  seated  gingivitis.  The  simple 
inflammations  are  more  liable  to  cause  resorption  of  bone  without 
loss  of  pericementum  at  the  gum  margin  while  the  septic  varieties 
are  usually  extensions  of  infective  conditions  from  the  gum  margin. 
Pyorrhea  alveolaris  is  a  destructive,  deeply  seated  gingivitis  and 
pericementitis  combined.  Ulceration  and  necrosis  following  extraction 
cause  gingivitis  (see  page  607). 

1  For  their  complete  article  and  different  varieties,  see  Jour.  Am.  Med.  Assn.,  June  2, 
1917,  and  synopsis  in  Dental  Cosmos,  1917,  p.  838. 

2  American  Text  Book  of  Op.  Dent.,  p.  300.  s  Dental  Cosmos,  1905. 

^  The  writer  has  introduced  the  term  to  replace  interstitial  gingivitis,  not  to  multiply 
terms,  but  because  it  indicates  fairiy  the  anatomical  situation.  Strictly  speaking, 
all  inflammations  are  interstitial. 


DEEPLY  SEATED  GINGIVITIS 


617 


If  at  any  time  pyogenic  infection  occur  at  the  gum  margin,  the 
purulent  phenomenon  of  pyorrhea  alveolaris  is  produced.  It  is  to 
be  understood  that  deeply  seated  gingivitis  presents  many  of  the 
features  of  pyorrhea  alveolaris  and  that  the  latter  is  a  gingivitis. 
The  conditions  are,  however,  pathologically  separable. 

The  following  is  a  good  example:  A  lady  presented  an  upper 
first  molar  which  had  had  a  pyorrhea  which  had  been  cured  by 
treatment  of  gum  margins  and  the  mesiobuccal  root  amputated. 
There  was  no  longer  any  appreciable  pus  pocket,  but  the  tooth 
overoccluded  one-sixteenth  inch  and  had  tipped  for\A'ard.  It  was 
not  supported  mesially  or  distally  by  adjoining  teeth.  It  was  loos- 
ened. The  overocclusion  was  removed  by  grinding,  the  tooth  was 
wedged  against  its  mesial  neighbor,  and  a  distal  amalgam  filling 
contoured  out  to  its  distal  neighbor,  thus  affording  support  in  the 
direction  of  its  movement  in  mastication.     It  became  much  firmer. 

Fig.  581 


Interstitial  gingivitis  on  molars. 

The  writer  considers  this  case  as  presented  for  diagnosis  one  of 
deeply  seated  gingivitis  due  to  non-septic  pericementitis  due  to  mal- 
occlusion and  non-support,  and  not  a  case  of  pyorrhea.  In  like 
manner  each  case  should  be  considered  on  its  own  symptoms. 

When  food  enters  the  interproximal  space  owing  to  faulty  contact 
it  crushes  the  gum  septum  and  later  depresses  it.  The  inflammation 
causes  its  absorption  as  well  as  often  that  of  the  bone  septum,  so  as 
to  leave  the  buccal  and  lingual  portion  higher,  forming  a  large  open 
pocket  for  retention  of  food.  This  may  also  be  inflamed  and  further 
depressed.  The  pericementi  of  both  teeth  suffer  necrosis  to  the 
gum  level.  The  pocket  may  finally  suppurate  and  a  lateral  abscess 
may  result  from  this  cause  called  a  septal  abscess.^  (For  Marginal 
Abscess,  see  page  609.)  A  wide  natural  space  between  teeth  does 
not  generally  produce  this  condition. 


1  Black. 


618     PERICEMENTAL  DISEASES  BEGINNING  AT  GUM  MARGIN 

While  this  may  be  classified  with  pyorrhea  alveolaris  it  seems  to 
the  writer  rather  a  distinct  form  of  deeply  seated  gingivitis,  at  least 
until  the  pus  flow  is  established.  The  writer  has  seen  another  form 
of  this  condition  in  which  caries  at  the  linguocervical  aspect  of  two 
molars  permitted  food  to  pack  laterally  (not  from  the  occlusal) 
under  tongue  pressure.  The  decay  proceeded  up  the  sides  of  the 
lingual  and  buccal  root  adjoining,  and  a  large  pocket  formed,  the 
gum  being  stripped  away.  The  wedging  out  of  the  gum,  touching 
with  silver  nitrate  after  cavity  preparation,  filling  with  amalgam, 
and  polishing  reduced  the  pocket  to  a  simple  one.  The  gum  grew 
in  as  far  as  it  could,  and  the  part  remains  relatively  healthy,  without 
pyorrhetic  symptoms,  but  food  collects  and  the  case  in  eight  years  is 
as  in  Fig.  582.  In  another  part  of  the  same  mouth  pus  was  found 
exuding  from  beneath  the  ulcerated  flap  of  gum  overlying  a  lower 
third  molar.     Otherwise  the  patient's  teeth  exhibited  no  pyorrhea. 


Fig.  582 


Fig.  583 


Resorption  probably  starting  with 
caries  and  continuing  it  (see  text.) 


Remarkable  case  (bilateral)  of  root  denu- 
dation. Note  the  bulge  of  the  root,  exact 
cause  not  known.     (Kindness  of  a  friend). 


Such  cases  might  be  considered  pyorrhetic  if  pyorrhea  is  to  include 
all  pus  flows  from  the  alveolus,  but  then  we  must  consider  apical 
abscess  such.  The  writer  believes  it  better  to  differentiate  the 
conditions. 

Systemic  Causes. — Systemic  causes  act  to  produce  a  deeply  seated 
gingivitis.  Drug  or  metal  poisoning,  or  auto-intoxication,  whether 
gastro-intestinal  or  by  leukomains,  and  acute  infectious  diseases, 
are  systemic  causes.     (See  page  572.) 

A  case  of  spontaneous  loss  of  all  but  one  of  the  upper  teeth,  with 
subsequent  complete  alveolar  atrophy  as  the  result  of  the  trophic 
disturbance  from  peripheral  neuritis  in  a  tabetic  woman,  has  been 
reported  by  Gaucher  and  Dobrovici,  the  diagnosis  being  confirmed 
by  trophic  disturbance  in  the  foot  followed  by  plantar  perforation. 

It  seems  quite  certain  that  in  conditions  of  general  faulty  metab- 
olism substances  are  generated  in  the  system  or  are  retained  by 


DEEPLY  SEATED  GINGIVITIS  619 

reason  of  faulty  elimination,  and  which,  floating  about  in  the  blood 
stream,  act  as  irritants  to  the  pericementi  and  gum  margins  about 
the  teeth. 

Moreover,  the  pericemental  glands  seem  to  be  eliminating  organs 
which  may  become  overstimulated  and  thus  diseased. 

In  all  general  nutritional  disorders  parts  peripheral  to  the  circu- 
lation are  most  affected,  become  debilitated,  and  tend  to  a  degener- 
ative metamorphosis  of  cells. 

As  some  proof  of  such  an  effect  in  another  peripheral  part  a  woman 
with  apical  granulomata  had  corrugated  finger  nails.  Within  two 
months  of  the  removal  of  the  teeth  mild  maniacal  symptoms  either 
concomitant  with  painful  neuritis  producing  insomnia  or  caused 
by  the  abscesses  has  disappeared  with  the  neuritis  and  insomnia 
and  the  finger  nails  are  assuming  normal  shape. 

Rhein  found,  after  repeated  examinations  of  hospital  patients,  that 
"marginal  gingivitis  was  an  accompaniment  of  typhoid  fever,  tuber- 
culosis, malarial  disorders,  acute  rheumatism,  pleurisy,  pericarditis, 
and  syphilis,  among  the  acute  diseases.  Of  chronic  nutritional  dis- 
eases, it  was  commonly  observed  in  cases  of  gout,  diabetes,  chronic 
rheumatism,  several  forms  of  nephritis,  scurvy,  chlorosis,  anemia, 
leukemia,  and  pregnancy.  Also  in  disorders  of  the  central  nervous 
system  and  following  the  administration  of  mercury,  lead,  and  iodin." 

Rhein  states  that  the  gingivitis  produced  by  each  of  these  diseases 
has  distinctive  features  which  may  even  serve  as  diagnostic  signs  of 
the  nature  of  the  general  malady. 

Talbot's  experiments  in  the  mercurialization  of  dogs  (see  page  568) 
demonstrate  that  efforts  upon  the  part  of  the  pericementum  to  elimi- 
nate the  bichlorid  of  mercury  result  in  a  non-septic  pericementitis, 
exhibiting  in  its  morbid  anatomy  the  characteristic  round-celled 
infiltration  of  inflammation. 

Black^  has  shown  that  a  gingivitis  produced  by  the  systemic 
administration  of  potassium  iodid  may  be  proved  to  be  caused  by 
its  elimination  by  the  pericemental  glands  by  test  of  the  gingival 
secretion  for  the  iodin  reaction. 

It  is  quite  reasonable  to  suppose  that  irritative  substances  origi- 
nating in  the  body  and  floating  in  the  blood  stream  may  act  in  like 
manner.     This  has  been  termed  auto-intoxication. 

Irritation  resulting  from  the  administration  of  mercury,  lead,  and 
iodin,  or  from  toxic  substances  absorbed  from  the  intestines,  is,  of 
course,  extrinsic  intoxication,  but  acts  in  the  same  manner. 

It  has  been  claimed  by  Hunter,  Herschell,  Goadby,  W.  B.  Keyes, 

1  American  System  of  Dentistry. 


620     PERICEMENTAL  DISEASES  BEGINNING  AT  GUM   MARGIN 

D.  D.  Smith,  and  others,  that  the  toxins  formed  by  oral  fermenta- 
tions and  the  septic  infection  of  the  stomach,  intestines,  etc.,  arising 
from  the  mouth  are  competent  to  excite  a  train  of  systemic  dis- 
turbances ending  in  a  general  malnutrition  (see  page  557). 

Certain  accomplished  cures  of  such  states  by  treatment  of  acute 
suppurative  conditions  in  the  mouth  and  even  constant  oral  pro- 
phylaxis lend  plausibility  if  not  certain  proof  to  this  argument. 
Still,  the  malnutrition,  whatever  its  cause,  oral  or  otherwise,  may 
become  a  predisposition  by  lessening  the  resistance  of  the  soft  parts 
about  the  teeth  to  local  irritants  or  add  the  irritation  due  to  auto- 
intoxication. 

Talbot  claims  that  interstitial  gingivitis  is  largely  due  to  auto- 
intoxication due  to  intestinal  fermentation  with  production  of  by- 
products, notably  indol,  which,  when  absorbed,  may  or  may  not  be 
eliminated  through  the  eliminating  organs — liver,  kidneys,  skin,  and 
lungs — and  that  if  these  be  insufficient  to  the  task,  retention  occurs 
and  even  further  disease  of  the  organs  themselves,  especially  the 
kidneys.  Constipation  aggravates  the  condition,  if  not  producing 
it,  by  retention  of  fecal  matter  with  which  the  poisons  should  be 
eliminated.  The  overstrain  of  the  kidney  in  the  endeavor  to  take 
up  the  work  of  the  liver  (when  that  is  diseased)  in  elimination, 
produces  renal  inflammation  and  impairment  of  eliminative  func- 
tion. 

The  blood  is  surcharged  with  accumulated  poisons,  the  heart  and 
arteries  degenerate,  and  cardiac  hypertrophy  and  arteriosclerosis 
are  produced.  Blood  pressure  is  increased  and  end  artery  and  nerve 
degeneration  occur,  in  the  brain,  eye,  alveolar  process,  pulp,  etc., 
being  noticeable  first  in  the  gums.  He  drawls  attention  to  the  transi- 
tory nature  of  the  alveolar  process  and  the  inability  of  the  arteries 
to  expand,  as  in  soft  tissues,  and  that  poisonous  products  settle  in 
the  end  arteries,  and  points  out  that  gingivitis  is  a  natural  result 
of  these  conditions.  The  demonstration  of  infarction  in  the  pulp 
due  to  systemic  conditions,  even  in  the  young,  has  been  made  by 
Hopewell-Smith,  and  also  indicates  end-artery  strain.    (See  page  420.) 

Talbot  regards  indican,  the  absorbed  product  of  indol  in  the 
intestine  due  to  putrefaction  and  which  is  found  in  the  urine,  as  the 
excitant  of  gingivitis  in  intestinal  fermentation  (auto-intoxication) 
and  the  general  acidosis,  as  indicated  either  by  an  excess  of  acidity, 
in  the  urine  or  a  deficiency  therein,  as  excitant  in  various  conditions 
of  malnutrition. 

The  excess  of  acidity  above  40°  in  the  urine  indicates  excessively 
imperfect  oxidation,  while  defective  acidity  (below  30°)  indicates 
insufficiency  of  renal  elimination.     In  both  cases  systemic  acidosis  is 


DEEPLY  SEATED  GINGIVITIS  .    621 

the  condition.  To  these  views  must  be  added  the  concept  of  intestinal 
putrefaction  caused  by  oral  infection  progressing  gradually  toward 
establishment  of  a  pyorrhea  or  deeply  seated .  gingivitis.  Thus  the 
profession  is  divided  into  two  schools:  (1)  Those  who  favor  a  sys- 
temic condition  as  a  cause  of  pyorrhea,  etc.,  and  (2)  those  who  regard 
a  systemic  condition  as  caused  by  oral  infections.  In  view  of  the  fact 
that  a  vicious  circle  is  established,  they  are  difficult  to  relate  as  to 
cause  or  effect  in  the  beginning.  Later  they  are  no  doubt  interrelated, 
one  predisposing  to  the  other. 

Black's  observations  upon  the  origin  of  calculus  in  the  blood  (see 
page  632)  shows  a  so-called  systemic  foundation  for  supragingival 
and  subgingival  calculus  deposition  and  their  ulterior  local  pathologi- 
cal effects  resulting  in  gingivitis. 

Diagnosis  of  Systemic  Causes. — The  diagnosis  of  systemic  cause 
by  malnutritional  conditions  involves  almost  the  entire  range  of 
medical  diagnosis,  a  subject  obviously  beyond  the  scope  of  this 
work.  If  local  causes  do  not  explain  the  oral  pathological  condi- 
tion it  is  well  to  refer  the  patient  to  a  competent  medical  diagnos- 
■  tician  for  examination  and  treatment.  Urinalysis  or  salivary  analysis 
may,  however,  be  made  by  either  the  dentist  or  a  specialist  in  that 
work,  and  together  with  symptoms  some  information  may  be  gained. 
Talbot  directs  that  twenty-four-hour  urine  should  be  obtained  and 
the  following  points  looked  for.^ 

Amount. — This  should  be  about  forty  ounces. 

Specific  Gravity. — If  high,  it  indicates  an  increased  proportion  of 
solids  per  ounce. 

Degree  of  Acidity. — If  above  40°  it  indicates  acidosis  by  imperfect 
oxidation;  if  below  30°  it  indicates  renal  insufficiency  and  retention 
in  blood  of  acid  products. 

Indican. — If  present,  it  always  indicates  intestinal  fermentation. 

Albumin. — Not  of  certain  origin. 

Hyalin  Casts. — If  bloody,  they  indicate  renal  inflammation. 
.  Compound  Hyalin  and  Coarsely  Granular  Casts  and  Waxy  and  Amyloid 
Casts. — Indicate  changes  in  structure  of  kidney. 

Symptoms. — Headache,  loss  of  appetite,  loss  of  memory,  irrita- 
bility, biliousness,  fatigue,  muscle  soreness,  hypochondriasis,  in- 
somnia, vertigo,  muddy  complexion,  tinnitus  aurium,  general  ner- 
vousness, cold  extremities,  impotence,  leg  cramps,  twitching  of 
muscles,  neurasthenia,  pruritus,  acne,  urticaria,  arteriosclerosis,  gout, 
rheumatism,  Bright's  disease,  diabetes,  uric  acid  diathesis,  nervous 
disorders,    asthma,    anemia,    lethargy,    stupor,    insanity,    etc.,    are 

1  Interstitial  Gingivitis  due  to  Auto-intoxication,  Journal  American  Medical  Asso- 
ciation and  Dental  Digest,  1906. 


622     PERICEMENTAL  DISEASES  BEGINNING  AT  GUM  MARGIN 

symptoms  which,  in  part,  may  develop  from  the  auto-intoxication 
by  the  toxins  and  acidosis. 

Unnatural  odor  of  the  breath,  armpits,  and  thighs  indicate  an 
effort  of  the  lungs  and  skin  at  elimination.^ 

Lead  poisoning  occurs  in  those  using  white  lead,  as  painters.  The 
occupation  together  with  paralysis  of  the  extensors  as  in  wrist  or 
foot-drop,  tremors,  and  peripheral  anaesthesia  from  toxic  peripheral 
neuritis  and  the  blue  lead  line  upon  the  gum  are  diagnostic  points 
with  which  mercurial  symptoms  of  like  character  may  be  confused 
though  urinalysis  for  lead,  the  history  and  occupation  clear  it  up. 

In  mercurial  poisoning  the  occupation,  history  of  drug  adminis- 
tration, salivation,  enlarged  tongue,  general  pericementitis  or  gingi- 
vitis, urinalysis  for  mercury,  will  clear  the  diagnosis  as  against 
that  of  lead  poisoning. 

Bismuth  subnitrate  used  in  pastes  for  treatment  of  fractures, 
filling  cavities  in  bone,  etc.,  has  occasionally  produced  gingivitis  by 
systemic  intoxication.    A  bluish  discoloration  of  the  gums  is  noted. 


Fig.  584 


Fig.  585 


Fig.  586 


Resorption  of  alveolar  process  due  to  interstitial  gingivitis,  caused  by  marginal  irri- 
tation from  excessive  filling  material.    (Radiographs  by  Price.) 


Pathology  and  Morbid  Anatomy. — The  local  or  systemic  causes 
produce  direct  inflammation;  the  bloodvessels  become  overful,  and 
waste  products  collected  in  the  end  arteries  produce  local  degenera- 
tion, diapedesis  of  leukocytes  into  the  interstitial  submucous  gum 
tissue  occurs,  and  the  spaces  are  filled  with  inflammatory  exudate. 
The  papillae  become  enlarged  and  the  epithelial  layer  undergoes  an 
increase  in  formation  of  cells  (hyperplasia) .  The  gum  in  consequence 
of  these  changes  becomes  swollen,  its  color  deepened,  and  it  bleeds 
readily. 

If  the  process  be  advanced  the  alveolar  process  is  involved. 

After  a  time  the  effects  of  continued  low-grade  inflammation  are 
expressed  in  resorption  of  bone  or  cementum,  or  hypertrophy  of 


1  Talbot. 


DEEPLY  SEATED  GINGIVITIS  623 

bone  or  cementum,  or  both,  as  the  two  processes  may  be  in  evidence 
at  the  same  time. 

Talbot  describes  several  forms  of  bone  resorption  occurring  in 
interstitial  gingivitis : 

(a)  Lacunar  resorption  carried  on  by  the  osteoclasts  normally 
lying  upon  the  surface  of  the  bone.  Under  irritation  they  increase 
in  number  and  excavate  irregular  bays  in  the  bone  (Howship's 
lacunae).  These  are  then  deepened  and  widened,  destroying  areas 
of  bone.     (See  Figs.  17  and  564.) 

(6)  Perforating  canal  resorption  beginning  in  the  small  canals 
normally  perforating  the  trabeculse  of  bone  in  various  directions  and 
transmitting  the  bloodvessels  from  one  medullary  space  or  Haver- 
sian canal  to  another  (Volkmann's  canals).  The  osteoclasts  widen 
these,  necessarily  reducing  the  substance  of  the  trabeculse  (Fig.  15). 

(c)  Halisteresis  ossium,  beginning  with  a  decalcification  of  masses 
of  the  bone,  the  organic  matrix  being  for  a  time  undisturbed,  but  is 
later  removed.  This  is  a  local  expression  of  what  may  occur  in  other 
bones  of  the  body  in  the  condition  known  as  osteomalacia  (Fig.  18). 

According  to  Talbot,  premature  resorption  of  the  alveolar  margins, 
either  local  or  general,  is  due  to  this  process,  called  by  him  alveolar 
osteomalacia,  and  occurs  in  pregnancy  or  senility,  as  a  rule. 

He  states  that  the  decalcified  bone  may  be  recalcified  after  con- 
finement in  pregnancy,  but  is  never  restored  in  senility. 

A  lesser  degree  of  irritation  may  set  the  osteoblasts  at  work  and 
cause  the  building  up  of  the  alveolar  process,  either  as  a  restoration 
of  resorbed  bone  or  as  an  hypertrophy  of  either  the  alveolar  process 
or  the  cementum  of  the  root  (hypercementosis) . 

Endarteritis  obHterans  is  a  thickening  of  the  intima  of  an  artery 
or  capillary,  due  to  chronic  irritation,  and  causing  a  lessening  of  the 
lumen  of  the  vessel,  even  to  the  point  of  obliteration  of  the  capil- 
laries. 

The  blood  flow  is  impeded  and  nutrition  of  cells  impaired.  Any 
cause  of  deeply  seated  inflammation  may  produce  it.  In  all  cases 
of  chronic  deeply  seated  gingivitis  the  bloodvessels  are  so  diseased 
(Figs.  587  and  588). 

Local  Treatment. — The  treatment  must  be  directed  to  the  removal 
of  the  underlying  cause.  All  local  causes  must  be  removed  and  the 
teeth  put  into  physiological  use  as  far  as  possible.  This  includes 
the  removal  of  causes  of  malocclusion  or  overuse;  of  the  crowding  of 
food  between  teeth,  the  removal  of  local  mechanical  irritants  and 
infective  agents.  The  local  treatment  in  general  is  that  employed 
for  marginal  gingivitis  or  for  pyorrhea  alveolaris.  (See  page  610; 
also  Pyorrhea  Alveolaris.) 


624     PERICEMENTAL  DISEASES  BEGINNING  AT  GUM  MARGIN 

Systemic  Treatment. — This,  of  course,  depends  upon  the  systemic 
condition  and  its  causes,  but  if  due  to  torpid  biliary  function  or 
defective  ehmination  with  consequent  retention  of  body  products, 
the  restoration  of  the  ehminative  function  should  be  aimed  at.  In 
intestinal  auto-intoxication,  impacted  fecal  matter  should  be  removed 
by  repeated  injections,  if  necessary,  of  warm  water,  and  the  bowels 
be  kept  clear  by  flushing  with  soap  and  water  once  or  twice  a  week. 
The  bile  function  should  be  restored,  and  the  bile  be  increased 
in  flow  by  calomel  and  soda,  yV  to  i  gr.,  every  hour  until  1  grain 
is  taken;  to  be  followed  by  a  saline  laxative  (as  Seidlitz  powder);  or 
podophyllin,  y^  to  |  gr.,  up  to  |  gr.,  may  be  given  instead  of  calomel. 


Fig.  587 


Fig.  588 


Fig.  587. — Longitudinal  seciion  of  gingival  border,  showing  round-cell  inflamma- 
tion, due  to  mercury,  and  extending  to  the  inner  coat  of  the  bloodvessel,  and  also 
plasma  mast  cells.    From  a  dog.    (Talbot.) 

Fig.  588. — Endarteritis  obliterans:  A,  adventitial  E,  elastic  tissue  between  middle 
coat  and  intima;  M,  muscular  coat;   /,  thickened  intima.     (Talbot,  after  Kaufmann.) 


Talbot^  also  uses: 

IJ — Aloin i  gr. 

Strychnin  sulphate g\f  gr. 

Extract  of  belladonna .      .      .      .      ^  gr. 

Pulv.  ipecac j-^  gr. — M. 

Take  at  bedtime  and  follow  with  a  saline  cathartic  next  morning. 
If  the  stools  remain  unhealthy,  administer  each  two  to  four  hours  2 
to  5  grs.  of  compound  lime,  soda  and  zinc  carbolate  until  the  stools 
are  healthy. 

1  Therapeutics  and  Treatment  of  Interstitial  Gingivitis,  Dental  Digest,  1906, 


MARGINAL  ATROPHY  OF  THE  GUMS  625 

to 
J  gr.  four  or  five  times  a  day. 

The  constant  use  of  heavy  Uquid  white  petrolatum,  for  the  purpose 
of  clearing  the  intestinal  mucosa,  by  lubrication  is  valuable.  Mas- 
sage of  the  abdomen  restores  the  tonicity  of  the  bowels. 

The  urine  should  be  examined  for  evidence  of  established  disease, 
and  if  this  be  found  the  patient  referred  to  a  general  practitioner. 
(See  General  Malnutrition.)  If  found  only  symptomatic  of  hepatic 
or  renal  insufficiency  and  nutritional  disorder,  the  amount  of  urine 
should  be  increased  to  40  ounces  by  the  drinking  of  3  pints  of  water 
(including  table  beverages)  per  day,  which  will  aid  bowel  and  renal 
elimination  and  flush  tissues  of  accumulations,  including  retained 
acids.  If  the  urine  be  abnormally  acid  (above  40°)  administer 
3-gr.  tablet  of  lithia,  sodium  bicarbonate,  or  sodium  chlorid  in  a  glass 
of  water  four  times  a  day.  Hot  or  Turkish  baths  keep  the  skin 
free  for  eliminative  function.  Well-apportioned  rest  and  exercise 
and  moderate  eating  of  proper  nutritious  food  are  indicated.  When 
organic  disease  is  present  the  treatment  should  be  relegated  to  the 
medical  practitioner. 

MARGINAL  ATROPHY  OF  THE  GUMS. 

In  advanced  age  there  exists  often  a  tendency  of  the  gums  to 
shrink  evenly  away  from  the  enamel,  exposing  the  cementum.  Hope- 
well-Smith describes  this  as  accompanied  by  fibroid  degeneration 
of  the  pericementum  (which  see);  and  regards  the  latter  as  a  purely 
senile  change. 

In  discussing  the  alveolar  conditions  antecedent  to  pyorrhea 
alveolaris  he  describes  a  resorption  of  marginal  and  radicular  bone 
of  the  halisteritic  type  followed  by  lacunar  resorption  extending 
finally  into  perforating  canal  resorption  which  constitutes  an  osteo- 
porosis^ (see  page  623).  The  alveolar  process  is  gradually  lost.  In  a 
later  paper^  he  gives  the  following  reasons  for  marginal  atrophy  in 
senile  (or  precocious  senile)  conditions:  (1)  The  thinness  of  the  alveo- 
lar margin  with  few  Haversian  canals  and  medullary  spaces  and  con- 
sequent inadequate  blood  supply  and  tendency  to  malnutrition  and 
atrophy.  (2)  Its  practically  fimctionless  character  due  to  lack  of 
muscular  attachment.  This  idea  is  elaborated  by  Roy^  who  claims 
that  senility  and  precocious  senility  due  to  causes  associated  with 
the  vitality  and  general  nutrition  of  the  individual  (especially  arthrit- 
ism)  is  the  systemic  cause  of  the  local  condition,  quoting  Bell,  DeBois, 

1  Dental  Cosmos,  1911.  p.  405.  ^  Ibid.,  May,  1918. 

'Ibid.,  1918,  p.  761. 

40 


626     PERICEMENTAL  DISEASES  BEGINNING  AT  GUM  MARGIN 

Talbot  and  Baume  as  previous  observers.  The  condition  seems 
inseparable  from  pericemental  degeneration  as  an  associated  process. 

It  may  be  noted  upon  the  buccal  side  only  of  a  denture,  and  be 
due  to  vigorous  brushing. 

It  is  also  seen  localized  at  cervices  next  to  a  space  from  which  a 

tooth  has  been  extracted.     In  one  case  the  editor  saw  a  slightly 

hypertrophied  gum  distinctly  overlapping  a  cavity  margin  drawn 

back  one-eighth  inch  within  a  month  as  the  result  of  extraction  of  the 

adjoining  foot. 

Fig.  589 


Recession  of  gum  in  senility;    beginning  decalcification  of  cementum;    alveolar  resorp- 
tion   after  extraction.     (Philadelphia  Dental  College  Museum.) 

It  may  be  that  collections  upon  the  teeth  are  in  some  degree 
responsible.  The  gums  have,  for  the  most  part,  a  healthy  look,  but 
are  in  a  condition  predisposed  to  pyorrhea  alveolaris. 

Treatment.^The  treatment  of  a  general  tendency  of  this  sort  is 
stimulation.  Brushing,  use  of  the  foods  requiring  mastication, 
massage  and  Bier's  hj^eremia  by  suction.  (See  Treatment  of  Pyor- 
rhea for  ideas.)  If  localized  to  a  particular  tooth  and  the  restoration 
of  the  gum  be  desirable,  Harlan's  method  may  be  tried.^  (1)  Cleanse 
the  exposed  tooth  surface  and  slightly  roughen  it  near  the  gum 
margin.  (2)  Dissect  away  the  gum  from  the  root  to  about  one- 
quarter  inch  in  depth,  wiping  the  blood  away  carefully  with  mouth 
open  until  hemorrhage  ceases  spontaneously,  or  check  with  adrenalin 
solution.    (3)  Make  three  incisions  into  and  through  the  gum  tissue. 

'  Dental  Cosmos,  19Q6,  p.  927,  and  1907,  p.  598. 


MARGINAL  ATROPHY  OF  THE  GUMS  627 

(4)  "When  bleeding  has  almost  ceased  fill  the  cuts  with  dried  zinc  iodid, 
allowing  the  blood  to  liquefy  it  so  that  it  may  be  carried  around 
the  gum  margin.  This  creates  a  profound  irritation,  which  should 
not  be  disturbed.  (5)  The  patient  should  use  a  mild  antacid  anti- 
septic wash;  as  of  sodium  bicarbonate  or  milk  of  magnesia.  (6)  Re- 
peat three  or  four  times  at  intervals  of  three  or  four  weeks,  with 
cuts  in  a  new  location.  (7)  Use  silk  or  pure  silver  ligatures  around 
the  teeth  under  the  gum  for  further  irritation.  (8)  To  allay  over- 
irritation  paint  with  1  part  adrenalin  and  3  parts  compound  tincture 
of  iodin  once  in  three  days. 

Harlan  states  that  a  long  time  may  be  required  in  some  cases.  It 
should  not  be  attempted  over  a  gold  filling,  but  an  unglazed  porcelain 
may  be  covered,  though  no  attachment  will  exist.  The  principle 
involved  is  that  of  coaxing  the  gum  into  adherence  with  the  roughened 
root,  and  the  filling  in  of  the  cut  with  scar  tissue. 

As  a  wash  use: 

H — Hydronaphthol .      gr.  xx 

Oil  eucalyptus TTlx 

Oil  cassia TTlx 

Alcohol f3iij 

Distilled  water fjxiij — M. 

Sig. — Use  freely  five  or  six  times  daily,  diluted,  if  necessary,  wnth  more  water. 

The  gums  should  not  be  brushed  for  several  days  after  operating. 
Avoid  insoluble  dentifrices.  If  this  treatment  be  considered  inad- 
visable the  appearance  in  a  given  case  may  be  improved  by  the 
use  of  a  pink  or  partly  pink  porcelain  inlay. 

For  general  recession  due  to  osteomalacia  the  general  acidosis 
may  be  treated  (see  p.  624). 


CHAPTER  XX. 
SALIVARY  AND  SERUMAL  CALCULUS. 

Calculi  are  more  or  less  hard  concretions  found  in  varying  situa- 
tions and  composed  of  inorganic  and  organic  matter  combined  in  an 
unknown  manner. 

As  related  to  the  teeth,  calculi  arise  from  the  following  recognized 
local  sources: 

1.  Obviously  from  the  saliva,  and  deposited  in  situations  which 
clearly  indicate  its  source,  salivary  calculus  (or  ptyalogenic  calculus 
— Peirce). 

2.  'From  the  serum  of  the  blood  deposited  at  some  point  along  the 
side  of  the  root  between  the  gum  margin  and  the  apex  of  the  root, 
and  called  serumal  calculus  (Black),  or  sanguinary  calculus  (Inger- 
soll).     Of  this  there  are  several  varieties: 

(a)  That  associated  with  a  probable  fermentation  and  an  altered 
secretion  from  the  gum  margin,  and  known  as  subgingival  calculus. 

(b)  That  occurring  in  situations  in  which  a  chronic  pus  flow  is 
found,  whether  apical  or  subgingival,  and  which  may  be  called 
pyogenic  calculus. 

(c)  That  found  upon  the  roots  of  teeth  at  a  point  to  which  saliva 
has  no  access  and  over  which  pus  does  not  flow,  and  which  is  there- 
fore deposited  by  the  lymph  derived  from  the  blood,  and  to  which 
the  appellation  hematogenic  calculus  (Peirce)  is  applicable. 

In  this  class  Kirk  found  two  varieties  resulting  from  pericemental 
inflammation:  (1)  Subpericemental  deposits,  and  (2)  intraperice- 
mental  deposits.^ 

These  several  names  will  be  adhered  to  in  further  descriptions  as 
having  definite  significance. 

The  experiments  of  the  late  Dr.  Black  seem  to  indicate  that  all 
these  deposits  are  explainable  upon  the  evidence  tending  to  show 
that  calculus  is  a  finely  divided  calcoglobulin  formed  into  spherules 
in  the  blood  and  thrown  into  any  location  which  favors  its  deposit. 
Apparently  they  therefore  have  a  common  origin  in  the  blood. 

SALIVARY  CALCULUS. 

Definition. — Salivary  or  ptyalogenic  calculi  are  hard  formations 
composed  mainly  of  calcium  salts  combined  with  organic  substances, 

»  Dental  Cosmos,  1905. 
(628) 


SALIVARY  CALCULUS 


629 


probably  a  globulin  or  globulins  into  minute  spherules  of  calco- 
globulin  which  have  been  deposited  in  a  soft  state  from  the  saliva 
upon  the  teeth  or  other  objects  in  the  mouth  and  have  hardened  in 
the  locations  where  deposited. 

OccuERENCE. — They  are  found  upon  the  surfaces  of  the  teeth, 
notably  in  situations  opposite  the  mouths  of  the  salivary  glands,  in 
the  ducts  of  the  muciparous  salivary  glands  (sublingual  and  sub- 
maxillary), and  upon  artificial  dentures.  A  photograph  of  a  plate 
containing  an  enormous  mass  of  calculus,  the  result  of  seven  years' 
accumulation,  is  shown  in  Fig.  590.  The  teeth  are  occasionally^ 
buried  in  it.  The  editor  extracted  three  lower  incisors  which  had 
been  wired  together,  and  were  absolutely  covered  from  the  neck  to 
the  apex  by  calculus  (Fig.  591). 

Varieties. — Clinically  two  distinct  varieties  of  salivary  calculus  are 
recognizable:  (1)  The  soft,  friable,  whitish  yellow  deposits  found 
chiefly  upon  the  buccal   surfaces  of  the   upper  molars   and  upon 

the  lingual  surfaces  of  the  lower 
^i«-  ^90  anterior  teeth;    (2)   dark-colored 

and  hard  deposits  found  more 
frequently  in  the  latter  situation, 
less  frequently  in  the  former.   , 

Fig.  591 


Salivary  calculus  attached  to  a  lower 
partial  plate  worn  seven  years  without 
removal.  Shows  form  of  sublingual 
space.  Practice  of  Dr.  Ford,  Toulouse, 
France.  (Specimen  in  possession  of 
Philadelphia  Academy  of  Stomatology.) 


Teeth  lost  by  salivary  calculus  formation 
(see  text) . 


Origin  of  Salivary  Calculus.  —  The  origin  of  salivary  calculus 
may  be  studied  from  several  standpoints:  (1)  The  formation 
of  calculi  in  other  parts  of  the  body;  (2)  an  analysis  of  saliva 
and  salivary  calculi;  (3)  extra-oral  experiments  upon  saliva 
with    a    view   to  the   formation  of   salivary   calculus   extra-orally; 

(4)  observations  upon  saliva  taken  directly  from  the  salivary  duct; 

(5)  the  changes  observed  clinically  in  salivary  calculus  during  its 
deposition. 

1.  Ziegler^  states  that  all  free  concretions  have  an  organic  basis 

1  General  Pathology. 


630  SALIVARY  AND  SERUMAL  CALCULUS 

or  nucleus  (inspissated  feces,  vegetable  material,  epithelial  scales, 
mucus,  etc.)- 

As  to  cholesterin  gallstones,  he  states  that  if  the  cholesterin  be 
dissolved  out  by  ether,  a  yellowish  organic  matrix  remains  which 
retains  the  form  of  the  stone  and  presents  upon  examination  radiating 
spaces  formerly  occupied  by  the  crystals.  He  describes  the  forma- 
tion of  the  gallstone  as  an  infiltration  or  incrustation  of  degenerated 
organic  matter  (epithelial  scales,  etc.)  with  cholesterin,  bile  pigment, 
etc.,  to  which,  after  a  nucleus  is  formed,  other  portions  are  added  in 
like  manner. 

Of  urinary  calculi  he  states  that  Ebstein  has  shown  an  organic 
substance  albuminous  in  nature  to  be  left  after  dissolving  out  the 
various  salts. 

In  stratified  calculi  this  stroma  also  shows  stratification.  Such  a 
stroma  may  be  seen  after  decalcification  of  a  bit  of  salivary 
calculus. 

Calculi  are  also  deposited  in  the  walls  of  degenerated  arteries  and 
in  degenerated  tissue  in  general  as  in  tumors  or  in  the  pulp  tissue 
(see  page  62) .  The  conditions  simply  favor  its  deposit  from  the  blood 
as  calculus  (calcoglobulin)  or  it  is  possible  that  a  reaction  occurs 
between  the  albuminous  elements  of  the  degenerative  tissue  and  the 
calcium  salts  in  a  sluggish  lymph.  Foreign  bodies  imbedded  in  the 
tissues  or  excretory  passages  may  also  have  calculus  upon  them,  as 
encysted  bullets  (Black)  or  objects  in  the  bladder. 

2.  Analysis  of  salivary  calculus  shows  it  to  be  composed  of  about 
22  per  cent,  of  water  and  organic  matter  as  the  portion  removable 
by  burning  the  calculus,  and  about  78  per  cent,  inorganic  matter  as 
the  portion  removable  by  decalcification  with  acids. 

Following  are  the  analyses  of  salivary  calculus  by  Stevenson  and 
Schehevetskey,  respectively:^ 

Soft  tartar  Hard  tartar  en 

on  molars.  lower  incisors. 

Water  and  organic  matter 21.48  17.51 

Magnesium  phosphate  ...,-....  1.31  1.31 
Calcium  phosphate  with  a  little  carbonate  and 

trace  of  fluorid 77.21  81.18 

100.00  100.00 

Water  and  organic  matter 22 .  07 

Magnesium  phosphate         1.07 

Calcium  phosphate 67.18 

Calcium  carbonate .8.13 

Calcium  fluorid 1.55 

100.00 
1  Talbot.     Interstitial  Gingivitis. 


SALIVARY  CALCULUS  631 

These  observers  are  practically  agreed  upon  the  substances  present 
in  calculus  as  mainly  calcium  phosphate  with  some  calcium  carbonate, 
calcium  fluorid,  and  magnesium  phosphate  combined  with  organic 
matter. 

Talbot  furnishes  the  following  analysis  of  serumal  calculus  by 
J.  H.  Salisbury:^ 

Water  and  organic  matter        32 .  24 

Magnesium  phosphate 0.98 

Calcium  phosphate 63 .  08 

Calcium  carbonate 3.70 

100.00 

To  these  Kirk^  adds  ammoniomagnesium  phosphate  as  a  product 
of  putrefaction. 

According  to  Mitscherlich,^  parotid  saliva  contains  globulin,  but 
no  mucin,  and  contains  calcium  carbonate;  calcium  phosphate  being 
present  in  but  minute  amount.  The  submaxillary  saliva  contains  a 
large  amount  of  mucin,  which  gives  to  mixed  saliva  its  viscid  nature. 

Analyses  of  submaxillary  saliva  and  mixed  saliva  by  Bidder  and 
Schmidt  gave  the  following  results: 

Submaxillary  Saliva. 


Water 991.45 

Organic  matter 2.89 

Calcium  chlorid 

Sodium  chlorid 


Inorganic  matter    < 


4.50 


Calcium  carbonate 

Calcium  phosphate  |- 1 .  16 

Magnesium  phosphate 


1000.00 


.   Mixed  Saliva. 

Water 995.16 

Epithelium 1.62 

Soluble  organic  matter        ;      .      .      .      .  1 .  34 


Organic  matter 


Potassium  sulphocyanid 0.06 

Inorganic  matter    \    Sodium,  calcium,  and  magnesium  phosphate     0.98 
Sodium  and  potassium  chlorid       .      .      .  0.84 


1000.00 


That  an  error  of  experiment  or  estimation  exists  in  these  analyses 
is  shown  by  the  fact  that  calcium  carbonate  is  not  mentioned  as 
existing  in  mixed  saliva,  while  it  exists  in  submaxillary  saliva;  this 
is  a  physical  impossibility. 

1  Talbot.     Interstitial  Gingivitis. 

2  Dental  Cosmos,  1905,  p.  752. 

2  Halliburton.    Physiological  and  Pathological  Chemistry. 


632  SALIVARY  AND  SERUMAL  CALCULUS 

It  is  presumptive,  however,  that  calcium  carbonate  has  not  been 
specially  estimated. 

If  a  bit  of  calculus  be  dried  and  then  burned  at  a  red  heat,  the 
organic  matter  present  will  burn  out,  the  calculus  retaining  its  form. 
If  a  similar  bit  be  subjected  to  dilute  acid  (1  per  cent,  nitric)  the 
inorganic  matter  will  be  removed,  the  calculus  will  float  to  the  top 
of  the  liquid,  and,  after  a  time,  remain  as  a  light  stroma  of  nearly 
the  original  form  of  the  piece. 

If  a  bit  of  calculus  be  transversely  ground,  it  is  seen  under  a  low- 
power  lens  to  present  a  laminated  appearance — i.  e.,  it  has  been 
deposited  in  layers  representing  periods  of  activity.  The  under 
surface  of  the  calculus  shows  a  concentric  formation.  Beneath  the 
mass  a  nidus  of  darker  calculus  may  be  found,  and  if  section  of 
extensive  calculi  be  made  the  greenish  deposits  may  be  seen  scattered 
through  the  mass.  Black  has  noted  the  presence  of  urates  in  nearly 
all  specimens  examined  by  the  murexid  test.  Foreign  bodies  are 
sometimes  entangled  in  the  mass.  Peirce  recorded  a  case  in  which 
a  small  clasp  plate  was  securely  fastened  to  the  teeth,  and  the  patient 
denied  possession  of  such  a  substitute  (see  also  Fig.  591). 

In  some  cases  extensive  salivary  deposits  are  found  associated 
with  highly  offensive  odors — i.  e.,  putrefaction  of  the  organic  matter 
occurs  as  a  part  of  the  process — indeed,  bacteria  are  constantly 
associated  with  the  mass  and  may  furnish  their  quota  of  the  organic 
matter.  Extraneous  matters,  such  as  tobacco  smoke  or  other  pig- 
ments, cause  discoloration  of  the  mass.  With  data  relative  to  the 
physical  and  chemical  analysis  of  calculi,  the  mode  of  calculus  forma- 
tion may  be  studied. 

3.  If  a  test-tube  be  filled  with  saliva  and  allowed  to  remain  at  rest 
for  several  days,  a  flocculent,  light  yellow  precipitate  will  be  noted 
at  the  bottom  of  the  tube.  If  the  supernatant  fluid  be  drawn  off 
with  a  pipette  and  the  precipitate  be  allowed  to  dry,  it  will  be  found 
possessed  of  the  chief  characteristics  of  calculus — hardness,  friability, 
a  light  yellow  color,  tenacity  of  adherence  to  objects  with  which  it 
is  in  contact,  and  capability  of  analysis  into  organic  matter  and 
inorganic  salts. 

4.  Dr.  Black's  studies^have  established  the  following  important  facts : 
(a)  That  minute  spherules  of  calcoglobulin  may  be  collected  from 

saliva  drawn  into  test-tubes  direct  from  Stenson's  duct  by  means  of 
a  canula  and  that  therefore  it  is  not  necessarily  dependent  upon 
oral  conditions.  As  the  saliva  was  found  sterile  the  combination  is 
not  necessarily  due  to  microorganisms. 

1  Text-book  Special  Dental  Pathology. 


SALIVARY  CALCULUS  633 

(b)  That  the  deposits  are  paroxysmal  in  character,  being  found  to 
take  place  only  for  a  limited  time  and  not  appearing  in  the  saliva 
of  the  same  individual  before  or  after  the  period  of  deposit  and  that 
the  period  of  the  "shower"  may  vary  from  a  half  hour  to  several 
hours. 

(c)  That  the  paroxysm  was  dependent  upon  the  quantity  of  nutri- 
tious food  taken  at  a  meal  rather  than  the  quality  of  it.  That  full 
meals  would  induce  it  while  a  half  meal  would  not. 

(d)  That  persons  in  ill  health  due  to  digestive  disturbances  might 
have  no  calculus  owing  to  non-assimilation  of  food  while  others  in 
"a  low   state  of   health"    might 

have  the  organic  portion,  globulin,  ^^__^^^°- ^92 

called  by  Black  "  agglutinin  of  cal-  ^  ^     '      '  ^^ 

cuius"  without  calcium  salts  in  it. 

(e)  That  examined   on  cover- 
glasses  specially  arranged  to  catch 
the    soft    calculus    entering    the 
mouth    the    spherules   rnay    be 
specially    stained  and  examined 
microscopically  with  the  finding  a,  nidus;  b,  calculus. 
of  several  varieties  reacting  differ- 
ently to  stains  indicating  that  the  agglutinin  base  may  vary  in  its 
albuminous  composition  and  in  the  amount  of  calcium  salts  in  the 
combination. 

(/)  That  on  plates  the  mucous  coating  could  be  washed  off  in 
running  water  while  the  calculus  could  not,  but  that  it  could  readily 
be  removed  with  a  brush  and  water  if  fresh,  but  that  if  twenty-four 
hours  old  it  has  begun  to  harden  and  is  difficult  of  such  removal,  and 
after  several  days  cannot  be  so  removed. 

(g)  That  he  was  unable  to  separate  the  calcoglobulin  into  its 
components  without  destroying  them  which  means  probably  a  firm 
chemical  combination. 

He  suggests  the  tentative  theory  that  overeating  creates  an  excess 
of  globulin  or  globulins  in  the  blood  which  when  in  variable  over- 
accumulation  are  thrown  out  with  secretion  or  excretions  probably 
in  combination  with  calcium  salts  as  spherules  of  calcoglobulin  which 
in  the  mouth  deposit  first  as  a  soft  mass  which  then  hardens  by 
decomposition  of  the  colloid  elements.  He  also  concludes  that  the 
serumal  deposits  have  a  similar  origin. 

The  blood  contains  about  0.8  per  cent,  of  inorganic  salts,  including 
those  found  in  salivary  calculi,  and  a  certain  percentage  of  them  is 
also  found  in  the  blood  corpuscles.  They  probably;  therefore,  exist 
in  body  cells  in  some  proportion. 


634 


SALIVARY  AND  SERVMAL  CALCULUS 


The  salts  are  also  taken  into  the  body  in  the  form  of  food.  Their 
appearance  in  the  various  excretions  and  secretions  of  the  body  is  to 
be  regarded  as  in  all  probability  an  effort  upon  the  part  of  the  system 
to  eliminate  a  superabundance  of  inorganic  material  from  the  body. 
They  are  therefore  in  readiness  for  combination  with  globulin  in  the 
blood. 

The  ingestion  of  quantities  of  animal  or  of  vegetable  food  rich 
in  phosphates,  or  the  excessive  liberation  of  the  phosphoric  acid  in 
malnutrition,   may  produce   an   excessive  elimination   of  these   in 


Fig.  593 


Fig.  594 


Unclean  necks  of  teeth,  salivary  calculus, 
and  green  stain.  (Philadelphia  Dental  Col- 
lege Museum.) 


A,  maxillary  sinus;  5,  ductof  Steno; 
C,  parotid  calculus;  E,  submaxillary 
gland. 


the  excretions  and  cause  a  tendency  to  the  production  of  calculi 
about  the  body.  This  condition,  known  as  phosphaturia,  is  observed 
in  certain  nervous  diseases,  rachitis,  osteomalacia,  leukemia,  gout, 
and  rheumatism,^  in  which  the  phosphaturia  is  symptomatic  of  an 
excessive  katabolism;  also  in  intestinal  disturbance  resulting  in 
imperfect  assimilation  of  food. 

Whether  taken  in  as  food  or  liberated  during  metabolism  it  is 
probable,  as  pointed  out  by  Talbot,  that  if  one  excretory  organ  fail 


1  Thompson.    Practical  Medicine. 


SALIVARY  CALCULUS 


635 


to  perform  its  office  in  full  degree  another  must  take  up  its  work. 
For  these  reasons,  in  any  bodily  condition  affecting  elimination  a 


C,  calculus;    S.L.C.,  sublingual  cavity;    S.L.GL.,  sublingual  gland. 

superabundance  of  inorganic  salts  and  globulin  may  appear  m  the 
blood  and  hence  in  the  saliva,  and,  probably,  in  even  the  secretions 
from  the  gingival  margins. 

Fig.  596 


\^v^/^i-q^^i  y 


Right  side,  abrasion  from  overuse;   left  side,  deposits  due  to  stagnation. 

That  the  deposit  of  calculus  may  have  some  dependence  upon  the 
superabundance  of  calcium  salts  ui  the  system  is  evidenced  by  the 
fact  that  in  young  children  but  little  calculus  is  deposited  upon  the 
teeth.    The  salts  are  needed  in  bone  formation. 


636 


SALIVARY  AND  SERUMAL  CALCULUS 


5.  That  rest  or  relative  quiescence  of  the  saHva  is  favorable  for  the 
localization  of  calculus  is  shown  by  the  fact  that  it  occurs  at  points 
which  are  ordinarily  not  subjected  to  agitation — i.  e.,  buccal  surfaces 
of  upper  molars,  lingual  and  labial  surfaces  of  lower  incisors. 

Adhesive  precipitations  of  newly  formed  and  very  soft  calculus 
form  in  these  latter  situations  in  the  course  of  the  day.  If  not  removed 
by  brushing  they  harden  and  thicken.  An  unused  side  of  a  denture 
often  accumulates  calculus  in  greater  degree  than  the  side  used  for 
mastication.  This  does  not  occur,  however,  if  the  brush  be  used 
properly  and  equally  vigorously  upon  both  sides. 

In  the  analyses  furnished  by  Stevenson  (p.  630)  it  will  be  seen 
that  hardness  is,  in  part  at  least,  due  to  an  increased  proportion  of 
inorganic  elements. 


Fig.  597 


Fig.  598 


Section  of  a  lower  incisor,  with  a  large 
deposit  of  salivary  calculus  impinging 
upon  and  causing  inflammation  of  the 
gum.     (Black.) 


Section  of  an  upper  molar  with  deposit 
of  calculus  on  its  buccal  surface,  causing 
inflammation  and  absorption  of  the  gum 
and  lower  border  of  the  peridental  mem- 
brane and  alveolar  wall.     (Black.) 


Pathological  Effects  of  Salivary  Calculus. — ^In  contact  with  the 
mucous  membrane  a  salivary  calculus  excites  first  marginal  gingivitis, 
and  later  deeply  seated  gingivitis  and  its  effects.  There  is  sometimes 
in  this  stage  the  wavy,  gnawing,  uneasy  sensation,  associated  with 
mild  inflammation,  and  the  pulp  being  supplied  with  excess  blood, 
becomes  hyperemic  and  the  teeth  respond  more  readily  to  thermal 
stimuli.  (See  p.  383.)  The  gum  margin  is  inflamed,  and  occasion- 
ally pyogenic  organisms  cause  pus  formation.  The  gum  margin 
recedes  and  coincidently  a  resorption  of  the  alveolar  process  is 
produced.    More  calculus  is  deposited  and  the  process  proceeds 


SALIVARY  CALCULUS 


637 


until  much  of  the  alveolar  support  is  lost.   Microorganisms  no  doubt 
aid  in  the  process  (see  Fig.  600  and  page  590). 

The  tooth  is  thus  progressively  loosened,  first  by  inflammation, 
later  b}^  loss  of  alveolar  process^  moves  about,  and  a  resultant  mechan- 
ical non-septic  pericementitis  occurs;  as  a  result  the  membrane  is 
thickened  and  the  alveolar  process  partially  resorbed  (Fig.  597). 
As  soon  as  the  alveolar  loss  is  considerable,  infection  usually  occurs 
and  suppuration  may  be  grafted  upon  the  results  of  mechanical 
irritation.  Increased  looseness  occurs  until  the  tooth  drops  out, 
unless  mechanically  held  in  place. 


Fig.  599 


Fig.  600 


Section  illustration  of  a  heavy  deposit 
of  salivary  calculus  on  a  lower  incisor, 
with  partial  destruction  of  the  alveolus 
of  the  tooth.      (Black.) 


Sectional  illustration  of  lower  in- 
cisor, with  deposit  of  salivary  cal- 
culus less  heavy  than  that  shown  in 
Fig.  599,  but  with  greater  destruc- 
tion of  the  alveolus.     (Black.) 


The  entire  process  may  occupy  but  a  few  years;  in  other  cases 
the  atrophy  of  the  alveolar  walls  is  very  slow.  I  have  recently  seen 
a  case  like  that  shown  in  Fig.  599  on  about  eight  lower  teeth.  The 
patient  had  not  consulted  a  dentist  for  thirty  years.  During  the 
following  three  years  but  little  accumulated.  The  patient  has  in 
the  meantime  suffered  from  a  severe  form  of  heart  disease  and  his 
low  diet  may  explain  the  absence  of  calculus  (as  per  Black's  theory 
of  calculus  formation,  page  634). 

It  has  been  shown  that  in  more  advanced  cases  and  even  in  some 
of  the  simple  ones  that  salivary  calculus  and  its  associate  putre- 
factions may  be  a  cause  of  systemic  infection  as  in  the  case  of  pyorrhea 
alveolaris,  some  of  these  clearing  up  upon  the  establishment  of  normal 
oral  cleanliness.     (See  Systemic  Effects  of  Pyorrhea.) 


638 


SALIVARY  AND  SERUMAL  CALCULUS 


Prognosis. — The  prognosis  of  this  condition  depends  upon  the 
extent  of  alveolar  atrophy.  If  the  loss  of  support  be  not  so  extensive 
as  to  cause  marked  loosening  of  the  tooth  or  teeth,  the  teeth  may 
be  retained  for  an  indefinite  period  if  they  receive  constant  prophyl- 
axis. If  markedly  loosened  they  must  be  splinted  so  as  to  render 
them  firm.  If  left  unsupported,  the  pericementum  is  certain  to 
degenerate,  owing  to  the  increased  mobility.  The  alveolar  atrophy 
will  continue,  and  probably  infection  of  the  degenerated  pericemen- 
tum occur.  Redeposit  is  almost  certain  unless  all  morbid  conditions 
are  removed  and  extraordinary  precautions  be  taken  as  regards 
cleanliness,  which  precaution ^s  are  difficult  to  carry  out  without  the 
aid  of  a  dentist. 


Fig.  601 


Fig.  602 


S.  S.  White  scalers. 


Jaquette  scalers.     (Courtesy  J.  W.  Ivory.) 


Treatment. — The  treatment  may  be  divided  under  three  heads: 
removal  of  deposits,  correction  of  the  effects  of  their  presence,  and 
prevention  of  their  recurrence.  The  sole  means  of  removing  salivary 
calculi  should  be  instrumental. 

It  is  frequently  recommended  that  mineral  or  some  of  the  organic 
acids  be  used  to  soften  the  deposits  or  facilitate  their  removal. 
Anyone  having  seen  a  case  in  which  a  solution  of  sulphuric  acid 
has  been  used  for  this  purpose  needs  no  further  warning  against 
the  application.  Acid  solutions  will  certainly  soften  the  deposits, 
but  at  the  same  time  inevitably  cause  a  roughening  of  the  enamel 
of  the  teeth  by  a  solution  of  the  calcium  salts.  To  be  sure,  the 
acid  does  affect  the  calculus  more  than  it  affects  the  enamel,  but 
the  roughened  surfaces  of  the  latter  not  only  invite  widespread 
deposits  of  fermentable  material,  but  render  certain  the  more  exten- 


SALIVARY  CALCULUS 
Fig.  603  Fig.  604  Fig.  605 

I       ■      U 


639 


Fig.  606 


No.  3  Scaler.      No.  11  Darby-       No.  9  Darby- Perry    Burton  Lee  Thorpe's 
Perry  scaler.  scaler.  scalers. 


Fig.  607 


Fig.  608 


Fig.  609 


Pyorrhea  scalers  Nos.  5  and 
6,  revised  set.  S.  S.  White 
Dental  Mfg.  Co.'s  Catalogue. 
Intended  for  use  between  teeth 
as  well  as  for  pyorrhea. 


Flat  scaler. 


No.  35  Darby  Perry 
excavator. 


11 


Fig.  610 


C.  Kirk's  scalers  with  dentate  ends,  designed  to  cut  into  calculus  as, 
well. as  maintaia  the  course  of  the  scaler  upon  the  root  side. 


640 


SALIVARY  AND  SERUMAL  CALCULUS 


sive  accumulations  of  calculi  in  the  future.^     After  oral  sterilization 
as  far  as  an  antiseptic  spray  or  mouth  wash  will  accomplish  it  the 


Fig.  611 


i        a       3 

FROMT 


I  2  3 

SIDE 


Smith  scalers. 
Fig.   612 


<VVWW\ 


Crenshaw  scalers.     (Courtesy  J.  W.  Ivor3\) 

'  Recently  a  proprietary  preparation  was  offered  me  for  removal  of  stains  with 
assurance  by  the  maker  that  no  injurious  acid  was  present.  I  highly  polished  the 
labial  of  an  extracted  tooth  and  applied  it  for  one  minute.  The  enamel  was  dulled 
and  roughened.  The  preparation  was  acid  to  litmus.  Such  preparations  sometimes 
are  useful  in  green  stain,  but  should  be  used  with  great  care  and  after  applied  imme- 
diately brushed  off  with  an  alkaline  powder  used  as  an  abrasive. 


SALIVARY  CALCULUS  641 

deposits  upon  the  crowns  and  roots  should  be  removed  by  means  of 
scalers,  nearly  all  used  with  a  draw  cut.  Dipping  the  instruments 
in  a  germicide  such  as  tincture  of  iodin  aids  in  preventmg  infection 
of  tissue  (see  asepsis).  The  mstruments  should  have  sharp  edges 
and  be  introduced  beneath  the  deposits,  so  that  the  gum  be  not 
unnecessarily  wounded.  The  scaling  should  be  continued  until  e\'ery 
surface  which  can  be  cleaned  by  these  instruments  is  perfectly  smooth. 

For  the  approximal  surfaces  of  the  lower  anterior  teeth  the  flat- 
bladed  instruments  should  be  used  with  the  push  cut,  or  that  in 
Fig.  60S  with  the  draw  cut.  Younger's  pyorrhea  scalers  are  very 
useful  (Fig.  623).     Thorpe's  and  Jaquette's  scalers  are  useful. 

For  the  removal  of  associated  subgingival  calculus  not  too  deeply 
placed  beneath  the  gum  a  No.  35  Darby-Perry  excavator  is  of  almost 
universal  utility.  It  is  used  with  the  draw  cut  for  the  most  part. 
A  pair  of  them  may  be  employed  and  made  safe-sided  by  round- 
ing one  edge  if  desired,  to  avoid  injury  of  the  gum  margin.  The 
back  of  the  instrument  may  be  sharpened  to  an  edge  for  a  push 
cut.     File  scalers  (Fig.  612)  are  useful  for  rubbing  off  calculus  that 

Fig.  613 


Moose-hide  wheels. 

can  not  be  scaled  off  as  a  flake.  All  of  the  calculi  visible,  and  all 
that  can  be  detected  by  their  roughness,  are  thoroughly  detached 
and  scraped  away  with  instruments.  The  surfaces  of  the  teeth 
are  next  cleansed  with  pumice  made  into  a  paste  with  glycerin  or 
liquid  soap  to  prevent  spattering,  and  with  a  few  drops  of  hydrogen 
dioxide  for  antisepsis;  flavoring  matter  such  as  liquid  KohTios  or 
cologne  may  be  added.  The  paste  is  applied  to  the  surfaces  of  the 
teeth  with  rubber  cups  (Young's  are  excellent),  or  Abbott's  or  Rob- 
inson's brush  wheels,  which  are  used  to  cleanse  the  labial,  buccal 
and  such  lingual  faces  of  the  teeth  as  they  will  reach  (Figs.  614  to 
618).  The  gum  should  not  be  injured.  "When  using  brush  wheels 
it  is  well  to  apply  the  brush  to  a  point  away  from  the  gum  and  spread 
the  bristles  against  the  tooth  as  it  is  carried  toward  the  gum.  The 
second  brush  in  Fig.  614  is  the  best  for  the  labial  surface  and  lingual 
of  biscuspids  and  molars,  and  the  third  one  for  the  Unguals  of  lower 
incisors.  They  may  also  be  used  in  the  angle  hand  pieces.  A  finishing 
bur^  is  useful  in  the  remo'V'al  of  thinly  distributed  hard  calculi  on  lin- 
gual and  occlusal  surfaces,  especially  in  the  mouths  of  smokers. 

1  Guilford  Lectures. 
41 


642 


SALIVARY  AND  SERUM AL  CALCULUS 


The  approximal  surfaces  of  the  teeth  are  cleansed  with  fine  linen 
tape  or  flat  floss  silk  or  occasionally  with  steel  or  German  silver  strips 
charged  with  the  pumice  paste.  More  inaccessible  parts  require  the 
hand  use  of  an  orange-wood  point  mounted  in  a  Jack  porte-polisher 
(Fig.  619).  It  is  advisable  to  repeat  the  polishing  with  precipitated 
chalk  and  the  same  carriers.  When  prophylaxis  is  frequent  chalk  is  a 
sufiicient  abrasive  except  perhaps  with  the  wood  point. 


After  cleansing,  the  associated  gingivitis  should  be  reduced  and 
the  bacteria  inhibited  while  healing  by  means  of  an  antiseptic 
astringent  mouth  wash.     (See  Gingivitis.) 

If  desired,  the  operation  may  be  divided,  the  gross  deposits  and 
subgingival  calculus  being  removed  at  the  first  sitting.  After  a  few 
days'  use  of  the  mouth  wash  the  stains  and  bacterial  plaques  upon 
the  teeth  and  any  overlooked  deposits  may  be  removed.  Tincture 
of  iodin  painted  over  the  teeth  brings  the  deeper  stains  of  the 
collection  into  prominence,  as  does  also  a  solution  of  potassium 
permanganate  and  both  are  reasonably  antiseptic. 

Register  states  that  a  forcible  spray  of  1  per  cent,  hydrogen  dioxid 
used  after  the  application  of  tincture  of  iodin  will  soften  the  stains 
and  render  them  more  readily  removable.  The  iodin  is  also  rather 
germicidal. 


SALIVARY  CALCULUS 


643 


Prophylaxis. — The  smoother  the  surfaces  of  the  teeth  are  made, 
the  longer  the  redeposition  of  calcuH  will  be  delayed.     Black  sug- 


FiG.  617 


Fig.  618 


Fig.  619 


gests  the  use  of  the  ordinary  chip  syringe  and  plain 
water,  a  forcible  stream  being  accurately  used  to 
wash  away  the  agglutinin.  As  a  means  of  calculus 
prevention  it  should  be  valuable. 

It  is  a  wise  measure  to  cleanse  the  teeth  before 
any  long  series  of  operations  is  undertaken,  and 
as  a  prophylactic  measure  in  the  combat  with 
caries  and  pyorrhea  alveolaris  the  operation 
should  be  frequently  performed.  Indeed,  the 
teeth  should  be  cleansed  frequently,  so  that  it 
may  not  be  necessary  to  remove  actual  salivary 
calculus,  except  in  those  cases  in  which  it  col- 
lects with  abnormal  rapidity.  A  stick  in  a  metal 
handle  for  self-prophylaxis  is  useful  if  the  patient 
will  use  it.  Accurate  personal  prophylaxis  with 
the  brush,  even  a  special  brush  is  of  great  impor- 
tance.    (See  Prophylaxis.) 

In  cases  of  very  rapid  recurrence  of  salivary 
deposits,  evidence  of  an  associated  systemic 
condition  should  be  sought  and,  if  recognizable, 
should  receive  appropriate  treatment.  If  not 
recognizable,  the  method  suggested  by  Black  of 
reducing  the  quantity  of  food  and  the  thorough     jack  porte-poiisher. 


644 


SALIVARY  AND  SERUMAL  CALCULUS 


mastication  of  such  as  is  taken,  may  be  conjoined  with  the  occa- 
sional use  of  Epsom  salt,  if  further  needed  as  suggested.  (See  page 
633.)  A  patient  treated  in  this  manner  by  reduction  of  a  heavy  meat 
diet  to  a  moderate  one  with  Epsom  salt  once  a  week  was  changed 
during  an  absence  of  three  months  from  one  whose  calculus  collection 
seemed  enormous  from  week  to  week  to  an  amount  for  the  whole 
period  about  equal  to  a  former  week's  collection. 

SUBGINGIVAL  CALCULUS. 

By  subgingival  calculus  is  meant  that  form  of  deposit  which 
occurs  beneath  the  free  gum  margin  and  between  it  and  the  tooth. 

Fig.  620 


CJ^  u/ 


A,  subgingival  calculus;     B,  receding 
pericementum.     (Black.) 


Resorption  of  the  septum  of  bone  and 
recession  of  the  gum  between  the  central 
and  lateral  incisors,  caused  by  deposits  of 
serumal  calculus  under  the  gingivae. 
(Black.) 


The  deposits  consist  of  small  scales  or  granules,  usually  quite  smooth 
and  much   darker   (olive  green)   than   salivary  calculi    (Fig.   620). 


Fig.  622 


The  alveoli  irreparably  destroyed  by  calcic  inflammation.     (Black.) 


Composition. — They  consist  mainly  of  calcium  phosphate  combined 
with  undetermined  organic  substances.     (See  pages  630  and  635.) 


SUBGINGIVAL  CALCULUS  645 

Cause  and  Pathology. — It  is  probable  that  some  degree  of  marginal 
gum  irritation  first  occurs,  though  many  cases  of  an  apparently 
healthy  gum  with  a  scale  of  calculus  beneath  it  are  seen.  Whether 
the  irritation  arises  through  fermentations  about  the  unclean  necks 
of  the  teeth  or  as  the  result  of  an  effort  upon  the  part  of  the  gum 
margm  to  eliminate  calculus  as  a  waste  from  the  system  is  not  abso- 
lutely certain. 

The  theory  most  tenable  in  view  of  Black's  demonstrations  is  that 
of  calculus  deposited  by  the  blood  through  the  gum  secretion. 
Bunting  imbedded  a  tooth  after  moving  it  about  slightly  so  as  to 
create  a  space,  applied  saliva  and  moved  the  tooth  frequently  finally 
causing  a  deposit  of  calculus  along  the  root.  He  questioned  if 
subgingival  deposits  in  pyorrhea  pockets  could  not  come  from  the 
saliva. 

Effects  and  Symptoms. — The  direct  effects  are  exerted  upon  the  gum 
margin.  The  gum  is  either  pushed  against  the  crystals  or  the  tooth 
movement  pushes  the  calculus  against  the  gum  which  is  irritated,  if 
mildly  resorption  occurs,  exposing  the  calculus;  if  more  severely 
gingivitis  occurs. 

At  times  the  resorption  is  accompanied  by  evident  marginal  inflam- 
mation, at  others  the  gum  margin  has  a  normal  color,  but  the  resorb- 
ing  portion  some  time  is  sharply  defined  by  a  fine  line  (or  crease) 
from  the  normal  gum  tissue,  especially  at  the  interdental  septum. 
In  a  more  advanced  stage  this  demarked  portion  appears  sunken  or 
atrophied,  and  may  have  a  sort  of  semihyalin  redness  characteristic 
of  the  inflammation.  At  times  the  gum  margin  appears  everted 
(Fig.  621  a).  If  the  deposit  occur  on  only  one  side  of  a  root  the 
effects  may  be  confined  to  that  side. 

The  lingual  root  of  an  upper  molar  is  often  exposed  for  a  con- 
siderable portion  of  its  length  by  successive  deposits  of  calculi.  The 
same  is  true  in  other  situations,  notably  upon  the  labial  surface  of  a 
lower  incisor.  This  might  be  called  a  form  of  marginal  phagedenic 
gingivitis. 

If  the  deposit  be  generally  distributed  about  the  neck  of  the  tooth 
the  resorption  is  more  equalized. 

In  some  cases  the  bifurcation  of  roots  may  be  exposed  and  calculi 
deposit  in  that  situation. 

In  some  cases  the  gum  margin  becomes  simply  atonic  or  passively 
congested  and  is  pushed  away  from  the  teeth  by  large  masses  of  the 
calculus,  which  undergo  lateral  accretion.  It  appears  as  a  flabby, 
thickened,  loosened  gum  margin,  which  readily  draws  about  the 
necks  of  the  teeth  if  the  calculus  be  removed.  I  have  noted  this 
in  cases  of  suboxidation  with  bluish  lips,  and  in  renal  insufficiency. 


646 


SALIVARY  AND  SERUMAL  CALCULUS 


Finally,  infection  may  occur  about  the  calculus  and  the  symptoms 
of    pyorrhea  alveolaris  be  implanted.     When   this  is  established. 


Fig.    623 


^=^/^^^ 


5      6 


9  10  II     12  13  14  15 

Younger's  new  set  of  pyorrhea  instruments.     (Revised  by  Dr.  Robert  Good.) 

Fig.  625 


Tompkins'  pyorrhea  scalers. 


calculi  may  be  deposited  farther  up  the  side  of  the  root.  This 
pathology  often  precedes  the  condition  of  pyorrhea  alveolaris  which 
may  supervene  if  pyogenic  organisms  enter  the  area. 


HEMATOGENIC  CALCULUS  647 

Treatment. — The  calculus  should  be  removed  by  means  of  delicate 
scalers  used  with  either  the  push  or  draw  cut,  as  most  convenient, 
after  which  astringent  antiseptic  mouth  washes  should  be  prescribed. 
The  subsequent  frequency  of  removal  of  causes  by  oral  prophylaxis  is 
of  great  importance.  Figs.  623,  624,  and  625  show  convenient  forms 
also  useful  for  the  deeper  pyorrhea  pockets.  In  most  cases  healing 
is  spontaneous  even  without  medication,  but  often  the  washes  are 
of  advantage.  If  pyorrhea  be  present  on  any  tooth  it  is  to  be  con- 
sidered separately. 

PYOGENIC  CALCULUS. 

Pyogenic  calculus  is  that  form  of  serumal  calculus  which  is  deposited 
at  parts  of  the  tooth  root  over  which  pus  more  or  less  continually 
flows.  Pus,  means  broken  down  blood,  hTuph  and  tissue  which  may 
contain  calculus  derived  from  the  blood  as  well  as  may  the  saliva 
(see  page  633). 

In  chronic  apical  abscess  the  root  end  may  become  encrusted  with 
it,  and  in  those  cases  in  which  apical  abscess  discharges  along  the 
pericemental  tract  it  is  common  to  find  over  the  area  fine  granular 
deposits  which  vary  in  color  from  a  light  yellow  to  a  reddish  brown. 

The  same  is  true  of  active  pyorrhea  pockets. 

This  calculus  prevents  the  healthy  apposition  of  the  gum  tissue 
to  the  roots,  probably  because  of  its  irritant  and  infective  nature 
(Figs.  513  and  629). 

Treatment. — All  such  calculi  should  be  removed  by  whatever 
means  possible,  which  may  necessitate  scraping  the  root  end  or 
its  side,  or  even  the  amputation  of  the  apical  end  of  the  root.  In 
some  cases  25  per  cent,  sulphuric  acid  or  Tartasol  may  dissolve 
it.     (See  pages  547  and  682.) 

HEMATOGENIC  CALCULUS  (Syn.  SANGUINARY  CALCULUS). 

This  form  of  serumal  calculus  occurs  upon  the  root  in  the  absence 
of  apical  abscess  or  a  primary  pyorrhea  alveolaris,  and,  therefore,  at 
points  not  acted  upon  by  saliva  or  pus;  hence  it  must  be  deposited 
by  the  blood  through  the  lymph,  probably  as  any  other  form  is 
deposited. 

Miller^  has  offered  satisfactory  evidence  of  this  in  a  description  of 
a  case  of  impacted  cuspid  well  embedded  in  the  bone,  and  not  in 
any  w^ay  exposed  to  either  saliva  or  pus  influence  except  that  at  a 

1  Dental  Cosmos,  August,  1901. 


648  SALIVARY  AND  SERUMAL  CALCULUS 

point  over  the  cusp  the  gum  underwent  suppuration  for  a  short  tinle. 
The  crown  had  undergone  resorption,  showing  local  irritation,  and 
an  olive-green  calculus  had  formed  upon  the  middle  third  of  the 
root.  Cases  of  pericemental  abscess  have  been  noted  opening 
upon  the  gum  face  and  presenting  dark  green  calculi  upon  the  root 
in  that  situation  (Fig.  233).     (See  Pericemental  Abscess.) 

Peirce  found  in  such  deposits  a  proportion  of  sodium  urate  as 
shown  by  the  murexid  test  and  the  cases  associated  with  goutiness 
of  the  patient. 

While  such  deposits  may  not  cause  immediate  irritation,  they  may 
in  time  excite  inflammation  and  necrosis  of  tissue,  resulting  in  a 
discharge  of  glairy  material  representative  of  the  condition.  This 
form  of  dental  disease  will  be  further  discussed  as  pericemental 
abscess. 


CHAPTER  XXI. 
PYORRHEA  ALVEOLARIS.     " 

General  Considerations. — In  a  general  way  pyorrhea  alveolaris  may 
be  defined  as  the  formation  of  a  progressive  gum  pocket  at  the  ex- 
pense of  the  marginal  portion  of  the  pericementum,  the  tooth  becom- 
ing progressively  loosened.  Usually  calculi  and  a  pus  flow  are  found, 
but  in  some  cases  neither  are  much  in  evidence. 

Perhaps  it  might  be  advisable  to  call  the  cases  of  pocket  with  pus 
flow  pyorrhea  alveolaris  and  to  apply  the  new  term  periodontoclasia 
to  those  cases  with  pocket  but  no  pus  flow.  The  latter  term  is  hardly 
more  applicable  to  J^oth  conditions  than  the  former.  Many  other 
names  have  been  preferred,  but  the  term  pyorrhea  alveolaris  as 
above  defined  is  the  one  generally  used. 

Apical  and  lateral  abscess  from  gangrenous  pulp  or  perforation 
are  excluded  and  for  present  consideration  a  primary  pericemental 
abscess  is  also  excluded.  The  alveolar  wall  may  be  more  or  less  intact 
and  rarely  either  be  exposed  and  necrotic  or,  as  more  generally  the 
case,  be  still  covered  with  its  internal  periosteum,  which  is  the  remains 
of  the  pericementum.  In  some  cases  the  bone  has  disappeared  by 
resorption  and  the  gum  tissue  forms  the  outer  covering.  Pyorrhea 
alveolaris  always  involves  the  consideration  of  marginal  and  deeply 
seated  gingivitis,  but  these  need  not  necessarily  be  pyorrhea.  It  is 
therefore  somewhat  difficult  to  differentiate  from  gingivitis  proper, 
as  any  form  of  gingivitis  may  later  assume  the  characteristics  of 
pyorrhea  owing  to  infection  (Fig.  634). 

The  disease  ceases  spontaneously  with  the  loss  of  the  teeth,  though 
the  alveolar  process  is  further  resorbed  as  after  any  extraction. 

From  a  prophylactic  standpomt  it  is  wise  to  remove  any  cause  of 
gingivitis  as  it  is  apt  to  lead  to  a  pyorrhea  which  is  usually  a  disease 
recpiiring  years  for  its  full  establishment  in  a  mouth. 

Causes.— It  seems  that  anything  which  may  induce  a  gingivitis 
may  initiate  the  process  when  infection  is  added  of  a  character  that 
will  destroy  the  pericementum  and  produce  the  pocket  at  its  expense. 

There  is  much  to  be  said  for  the  theory  of  Talbot  that  as  individuals 
approach  the  degenerative  period  of  life,  the  more  transitory  struc- 
tures less  essential  to  maintainance  of  life  tend  to  degeneration,  e.  g., 
the  alveolar  process  tends  to  resorptions  as  particularly  noted  in 

( 649 ) 


650 


PYORRHEA  ALVEOLARIS 


general  murginal  resorption  of  gum  and  bone.     (For  further  details, 
see  p.  625.) 

This  condition  of  presenility,  while  claimed  to  be  a  forerumier  of 
general  pyorrhea  by  Talbot,  Hopewell-Smith,  Hecker,  Roy,  Cazier 
and  others,  is  not  claimed  to  cause  pyorrhea  by  itself,  but  to  act  as  a 
predisponent  to  local  infections  and  a  complication  when  it  is  estab- 
lished. This  is  also  much  confused  by  the  fact  that  so  many  causes 
of  local  irritation  of  mechanical  nature  with  their  consequent  inflam- 
mation of  gum  margin  or  pericemental  inflammation  (with  resorption 
of  bone),  and  by  constant  uncleanliness  and  probable  infection  of  the 
gingival  tissues  that  in  most  cases  it  can  only  be  a  surmise.    The  fact 

Fig.  626 


Endameba  buccalis.     Illustrating  nuclei,  ingested  matter  and  bacteria,  also  at  A  and 
B  the  ectoplasm  and  ectosarc.     Half  second  intervals.     (Price.) 

that  pyorrhea  usually  occurs  after  thirty  years  of  age  in  some  degree 
bears  this  theory  out,  but  again  other  causes  have  gradually  accumu- 
lated. Hopewell-Smith^  considers  the  constant  infection  of  the  gingival 
trough  a  predisponent  of  the  degeneration.  Any  of  the  causes  which 
produce  chronic  non-septic  pericementitis  (see  page  589),  may  produce 
an  inflammatory  degeneration  which  will  produce  looseness,  mal- 
occlusion, etc.,  tending  to  mechanically  increase  the  inflammation. 
This  is  generally  recognized  as  a  cause  of  pyorrhea  in  that  it  predis- 
poses to  the  development  of  bacteria  already  in  the  gingival  trough. 
The  pyorrhea  produces  more  looseness  so  that  a  vicious  circle  is 


1  Dental  Cosmos,  1918,  p.  428. 


GENERAL  CONSIDERATIONS 


651 


established.  The  narrowness  of  the  necks  of  teeth  (m  conjunction 
with  length  of  crowns  at  times)  is  also  a  predisponent  to  infection 
in  that  bacterial  collections  are  more  readily  formed,  or  calculus  and 
food  deposited.  Again  this  cause  is  aggravated  and  malocclusion 
introduced  when  teeth  tilt  in  consequence  of  extraction.  IMechanical 
irritants  such  as  crown  margins,  calculus  beneath  the  gum  margin, 
also  institute  an  inflammation  favorable  to  bacterial  action. 

The  Infective  Element. — ^]Much  work  has  been  done  to  determine  the 
primary  infective  cause  of  pyorrhea. 

The  present  thought  is  that  pus  formation  is  a  secondary  effect 
implanted  upon  a  primary  infection  of  non-pyogenic  character.    That 

Fig.  627 


Endameba  Kartulisi.     Showing  organism  starting  on  a  journey  and  its  progress 
in  six  seconds.     Half  second  intervals.     (Price.) 


is,  that  mainly  the  pyogenic  bacteria  enter  a  prepared  field.    Regard- 
ing this  primary  infection  two  views  are  mainly  discussed: 

1.  That  the  cause  lies  in  oral  endamebge. 

2.  That  bacteria  are  the  causes. 

1.  In  1914  Smith  and  Barrett^  announced  their  belief  that  endameba 
gingivalis  (Gros)  was  a  protozoal  cause  of  pyorrhea  alveolaris.  It 
also  has  the  name  Endameba  buccahs.  In  a  paper  written  in  1915- 
They  reaffirm  their  belief,  havuig  then  accumulated  325  cases  and 
demonstrated  their  presence  in  318  of  these.  They  do  not  claim  that 
all  cases  are  due  to  them,  but  recognize  spirochetes  and  other  bacteria 

1  Dental  Cosmos,  August,  1914. 

2  Dental  Items  of  Interest. 


652  PYORRHEA  ALVEOLARIS 

as  possible  causes  of  a  reasonably  small  number  of  cases.  Cliiavaro^ 
also  found  them  in  1914,  but  regarded  them  as  harmless  commensals. 

Bass  and  Johns-  claim  to  have  found  them  in  the  depths  of  care- 
fully examined  pockets  in  nearly  all  of  several  hundred  cases  of  pyor- 
rhea "disappearing  as  the  lesions  get  well."  This  finding  in  all  cases 
has  not  generally  been  confirmed. 

Smith  and  Barrett  and  Bass  and  Johns  state  them  not  present  in 
really  normal  gums  while  Park  and  Williams'*  state  that  they  are 
found  in  the  mouths  of  a  majority  of  children  without  definite  rela- 
tion with  the  beginning  of  pyorrhea.  As  pointed  out  by  Smith  and 
Barrett  this  is  merely  a  prevalence  of  cause  not  a  proof  of  non- 
pathogenicity.  Bass  and  Johns  claim  that  endamebse  engulf  bacteria 
and  carry  them  into  deeper  parts  of  the  pockets,  to  there  de\elop. 

Smith  and  Barrett  argue  for  a  possible  symbiotic  relationship 
between  endamebae  and  bacteria,  i.  e.,  the  action  of  bacteria  is 
implanted  upon  a  field  prepared  by  the  endamebee,  while  others 
argue  that  as  the  endamebse  phagocyte  large  numbers  of  bacteria 
they  are  commensals  and  mere  scavengers  or  even  beneficial.''  Hart- 
zell  and  Henrici  were  unable  to  find  them  in  the  living  ulcerated  tissue 
forming  the  border  of  pyorrhetic  pockets,  but  Price  fomid  a  Ivartulisi 
in  such  tissue. 

Price^  found  endamebse  in  cases  after  treatment  with  emetin  when 
none  could  be  fomid  before  or  during  treatment  of  some  cases. 

Endameba  kartulisi  is  also  found  and  occasionally  those  of  the 
Endameba  coli  type.^  Endamebee  are  uncultivable  in  media  and 
Ivoch's  postulates  are  considered  at  present  impossible  of  fulfil- 
ment. Smith  and  Barrett  have  kept  them  alive  seventy-two  hours 
in  solution  of  egg  white.  The  basis  upon  which  these  claims  rest  is 
theu"  common  presence  in  the  lesions  and  their  vulnerability  to  dilute 
solutions  of  emetin  1  to  100,000  or  less  which  is  not  also  germicidal 
(the  usual  0.5  per  cent,  being  so)  and  theu*  vulnerability  to  emetin 
h^'podermically  or  alcresta  ipecac  internally  (see  therapeutics)  which 
when  reaching  the  pericementi  is  at  least  1  to  200,000  dilution.  Iveyes^ 
followed  Barrett's  technic  with  success.  Rhein^  (also  Kells^),  cured 
a  case  w^ith  it  when  other  treatment  failed  and  the  author  has  had 
occasional  success  in  obstinate  cases  otherwise  treated.     There  is  a 

1  Dental  Cosmos,  September,  1914.  ^  Text  Book  Alveolo  Dental  Pyorrhea. 

3  Text  Book  Pathogenic  Microorganisms,  p.  531. 

^  See  Hartzell  and  Henrici:  Journal  of  National  Dental  Association,  1915,  p.  128, 
for  elaborate  arguments  to  this  effect. 

°  His  splendid  series  of  arguments  for  and  against  the  causal  relation  of  endamebse 
may  be  found  in  the  Journal  of  the  National  Dental  Association,  Mas',  1915. 

6  Ibid.,  p.  23.  ^  Dental  Cosmos. 

8  Dental  Items  of  Interest,  December,  1916,  p.  883. 


GENERAL  CONSIDERATIONS  653 

tendency  to  abandon  the  theory,  but  to  the  writer  it  still  seems  pos- 
sible while  no  other  is  proved  absolutely.  Two  forms  of  technic  have 
been  suggested  for  microscopic  examination. 

Smith  and  Barrett  take  the  purulent  contents  from  the  bottom 
of  the  pocket,  diffuse  this  in  a  drop  of  slightly  warmed  saline  solution 
on  a  warmed  slide  and  immediately  examine  it  while  living  with  a  4 
mm.  lens.  (Bass  and  Johns  suggest  the  use  of  5  or  6  times  the  quan- 
tity of  saliva  as  keeping  them  alive  a  longer  time.)  They  describe  it 
as  having  active  ameboid  movements  for  about  fifteen  minutes,  but 
eventually  becoming  quiescent.  They  vary  in  size  from  6  or  8  mi.  to 
30  mi.  in  diameter.  They  have  a  clear  ectosarc  which  extends  when 
pseudopods  form  and  a  coarsely  granular  endosarc  which  extends 
but  slightly  and  contains  numerous  food  vacuoles  containing  frag- 
nients  of  leukocytic  chromatin  and  apparently  portions  of  red  blood 
cells.  No  contractile  vacuole  exists.  Motile  and  non-motile  bacteria, 
epithelial  scales,  leukocytes,  etc.,  are  present  in  the  microscopic 
field. 

Smith  and  Barrett  suggest  the  following  method  of  staining: 

1.  Fix  in  warm  saturated  solution  of  bichlorid  of  mercury  in 
alcohol. 

2.  Stain  with  Giemsa's  stain. 

Bass  and  Johns^  stain  them  by  the  following  technic: 

1.  The  material  from  the  bottom  of  a  pocket  is  spread  thinly  on 
a  microscopic  slide  and  fixed  carefully  by  heat. 

2.  This  is  then  covered  with  one  or  two  drops  of  carbol-fuchsin 
and  then  washed  off  at  once  with  water. 

3.  One  or  two  drops  of  Loffler's  methylene-blue  solution  is  applied 
for  fifteen  to  thirty  seconds. 

4.  This  is  then  washed  off  with  water  and  dried  with  a  blotter  or 
by  fanning  in  the  air  for  a  few  minutes.  When  properly  stained  the 
film  appears  purple  to  the  eye.  It  should  not  be  overstained  with 
methylene  blue  as  this  displaces  the  red  stain.  At  the  right  point, 
sharp  contrasts  of  value  occur. 

The  examination  is  made  with  an  oil  immersion  lens.  The  following 
dift'erentiations  in  the  field  are  noted  by  Bass  and  Johns. 

Staining  Pink. — Some  bacteria,  red  blood  cells  (also  in  the  enda- 
moeba),  cytoplasm  of  pus  cells  (leukocyte),  cytoplasm  of  epithelial 
cells,  ectosarc  of  endamoebse  (sometimes  light  purple),  nucleus  of 
endamoebfe. 

Staining  Purple. — Some  bacteria  as  spirochtetes,  nuclei  of  pus  cells 
(leukocytes),  nuclei  of  epithelial  cells,  cytoplasm  of  some  large  cells 

1  Text  Book,  Alveolo-Dental  Pyorrhea, 


654  PYORRHEA  ALVEOLARIS 

from  granulating  surfaces,  ectosarc  of  endamoeba,  at  times  a  light 
purple,  endosarc  of  endamoebee. 

Staining  Blue. — Some  bacteria,  sometimes  endosarc  of  endamoebae. 

2.  Opposed  to  the  amoebic  theory  is  that  of  Hartzell  and  Henrici^ 
for  streptococci,  Noguchi  for  spirochsetes  or  treponemata  and  Medalia 
and  others  for  mixed  bacterial  infections.  Hartzell  and  Henrici,  from 
numerous  observations,  state  that  the  gingival  crevice  is  always  open 
and  subject  to  infection  from  tooth  sm'f aces  and  saliva  (see  page  650) . 
That  the  veins  and  perivascular  lymph  spaces  can  carry  infection  from 
the  gingival  crevice  to  the  peridental  membrane  (and  socket  apex), 
which  movement  of  infectious  material  is  aided  by  the  enormous 
force  of  mastication.  That  when  proper  care  to  exclude  extraneous 
infection  is  used  the  peridental  tissues  ahcays  prodvce  grouih  of 
Streptococcus  viridans.  In  another  article  they  consider  pyorrhea 
primarily  a  granulomatous  growth  analogous  to  apical  granuloma 
(primarily  non-purulent).  Hopewell-Smith^  adds  Micrococcus  ca- 
tarrhalis  and  mentions  epithelial  debris,  phagocytes,  together  with 
countless  bacteria  as  a  normal  state  of  the  gingival  trough. 

Hartzell  and  Henrici  further  state^  that  oxygen  can  be  blown  under 
compression  into  the  gingival  crevice  and  into  the  tissues  evidencing 
"physical  imperfections"  (probably  normal  spaces)  (see  Emphy- 
sema, page  504).  Later  other  pyogenic  bacteria  enter  and  produce 
pus.  Spirochetal  forms  of  bacteria  are  frequently  found  in  the 
pockets,  notably  the  following: 

"A  large  spirochete  w^ith  wide  curves  in  its  spiral,  morphologically 
greatly  resembling  the  spirochete  of  recurrent  (relapsing)  fever 
(Kolle^).  Treponema  mucosum  producing  the  odor  of  pyorrhea  in 
its  medium  (Noguchi)".^ 

The  use  of  salvarsan  both  locally  and  systemically  is  antagonistic 
to  them,  hence  by  therapeutic  test  they  are  claimed  as  a  cause  by 
(Kritchevsky  and  Seguin*).  It  may  be  that  such  success  as  is 
achieved  by  succinainide  of  mercury  hypodermically  administered  is 
to  be  regarded  as  also  some  like  evidence  as  they  disappear  after  the 
treatment.  The  spirochetal  forms  remain  after  endamoebse  disappear 
and  are  subject  to  iodin  locally  applied  or  any  one  of  the  arsenical 
group  as  neosalvarsan  or  arsenobenzoP  (Smith  and  Barrett). 
Kritchevsky  and  Seguin  have  ably  illuminated  this  view  (page  690). 

1  Conveniently  found  in  Dental  Items  of  Interest,  December,  1916,  p.  932,  also  see 
Journal  of  National  Dental  Association,  May,  1917,  p.  123. 

2  Journal  of  National  Dental  Association,  May,  1917,  p.  492. 

3  Dental  Cosmos,  May,  1918,  p.  428. 

4  Dental  Cosmos,  1918,  p.  781.      ^  Journal  of  Experimental  Medicine,  1912,  p.  194. 
s  Dental  Review,  October,  1915. 


GENERAL  CONSIDERATIONS  655 

They  used  neosalvarsan  intravenously  and  succinamide  of  mercury 
intramuscularly  in  cases  of  marked  pyorrhea  with  and  without  local 
treatment  and  eflfected  almost  complete  disappearance  of  spirochetes, 
claiming  that  only  the  rarer  and  inactive  forms  remain.  They  also 
confirm  Smith  and  Barrett  in  their  claim  of  value  for  neosalvarsan 
used  in  the  pockets.  They  advise  also  local  surgical  treatment  and 
subsequent  prophylaxis,  not  claiming  any  establishment  of  immunity 
from  recurrence,  also  that  much  loosened  teeth  should  be  extracted. 
(See  Treatment.) 

Medalia,  in  1913,^  before  these  demonstrations  made  scientific 
studies  of  the  bacteria  found  in  mild  and  advanced  cases  together 
with  those  found  in  the  feces  of  the  same  patient  and  compared  the 
finding  with  the  opsonic  index  of  the  patient  to  the  prevailing  bacteria. 
In  112  cases  he  found  by  direct  examination  of  smears  and  cultural 
findings  the  following  important  bacteria. 

Bacteria. 

Times. 

Pneumococcus  (in  chains  or  diplococcus  forms) 26 

Pneumococcus  and  staphylococcus  together 67 

Pneumococcus  and  streptococcus  together 3 

Pneumococcus,  streptococcus  and  staphylococcus 10 

Pneumococcus  and  Micrococcus  catarrhalis 1 

Staphylococcus  and  Micrococcus  catarrhalis 2 

Staphylococcus  aureus 2 

Staphylococcus  and  streptococcus       .     ". 1 

Sterile 3 

In  85  advanced  cases  the  cultural  findings  were  practically  in  the 
same  proportion.  The  opsonic  index  of  49  of  the  patients  was  as 
follows. 

Bacteria. 
Pneumococcus  . 
Staphylococcus 
Streptococcus    . 
Colon  (B.  coli) 

These  patients  treated  by  appropriate  vaccines  made  marked 
improvement  when  local  treatment  was  conjoined,  the  results  in 
the  incipient  and  moderately  advanced  cases  being  almost  perfect 
while  in  advanced  cases  out  of  85,  37  were  reported  cured,  40  bene- 
fited, 4  unimproved,  3  dropped  out  of  treatment.  These  findings 
seem  to  show  at  least  that  the  above  bacteria  are  at  least  strongly 
complicating  factors  in  at  least  maintaining  a  pyorrhea. 

The  present  view  of  bacteriologists  that  the  Streptococcus  viridans 
may  assume  both  a  streptococcal  and  pneumococcal  form  (diplo- 

1  Dental  Cosmos,  1913,  p.  24;  150,  704. 


Below 

Above 

Not 

normal. 

normal 

Normal. 

tested. 

Total. 

39 

2 

7 

1 

49 

25 

1 

20 

3 

49 

4 

— 

32 

13 

49 

18 

3 

12 

16 

49 

656  PYORRHEA  ALVEOLAR! S 

coccus)  tends  to  harmonize  the  views  of  Medalia,  and  Hartzell  and 
Henri  ci. 

These  demonstrations  while  rendering  the  subject  of  bacterial 
infection  clearer  have  not  finally  disposed  of  the  problems  as  to 
whether  the  Streptococcus  viridans,  etc.,  acts  as  a  direct  cause  or 
awaits  the  primary  action  of  calculus,  etc. 

There  are  two  views  regarding  the  calculus  found  in  pyorrhea  cases: 

1.  That  it  is  primarily  deposited  under  the  gum  margin  (see  theories 
of  Black,  Bunting,  etc.,  page  632),  and  becomes  an  irritant,  causes 
inflammation  mechanically  and  this  favors  further  action  by  bacteria. 

2.  That  infection  occurs,  irritates  tissue,  causes  abnormal  secretion 
in  which  the  elements  of  calculus  are  contained  which  combine  and 
precipitate  as  calculus  or  the  calcospherites  of  calculus  are  thrown 
out  in  the  secretion  as  in  the  saliva  (see  page  632)  and  deposit  on 
the  tooth  neck. 

In  either  case  calculus  formation  is  an  early  stage  in  the  production 
of  pyorrhea. 

That  there  are  some  cases  in  which  the  infection  and  inflammation 
precede  any  clinically  evident  calculus  formation  is  a  known  fact 
as  shown  by  a  bright  red,  acutely  infected  gum  margin.  This  when 
treated  early  by  mechanically  cleansing  and  chemically  disinfecting, 
the  part  is  at  least  temporarily  cured.  It  is  usually  noted  in  mouths 
in  which  a  more  advanced  infection  may  elsewhere  be  found. 

Granting  the  fairly  established  fact  of  the  common  infection  of  the 
gingival  trough  before  any  appearance  of  calculus  and  the  gradual 
accumulation  of  infection  and  calculus  through  a  series  of  months  or 
years  and  the  usual  cure  when  cleanliness  is  established,  it  is  rational 
to  assume  that  the  second  theory  above  described  is  at  least  a  work- 
ing theory  upon  which  prophylaxis  and  cure  may  be  based  until  the 
actual  facts  shall  be  proved.  Therefore  in  obser^'ing  mouths  at  all 
times  one  should  look  ahead  for  all  forms  of  gingivitis  or  causes 
liable  to  produce  it  to  a  possible  futm-e  pyorrhea  and  take  measures 
to  prevent  it  (see  page  650). 

Clinically,  fully  established  cases  of  pyorrhea  alveolaris  may  be 
divided  into  three  classes:  (1)  Cases  associated  with  a  primary 
gingivitis  and  with  the  formation  of  hard,  scaly,  dark,  annular 
calculi  beneath  the  gum  margin  (subgingival  calculus),  the  pockets 
not  usually  extending  far  beyond  the  deposits;  (2)  cases  beginning 
with  a  marginal  gingivitis  and  apparently  not  dependent  upon  the 
association  with  calculus,  though  frequently  complicated  by  it; 
(3)  cases  having  an  apparent  origin  at  some  point  between  the 
gingival  margin  and  the  apical  tissue,  the  gingival  margin  at  first 
being  apparently  intact. 


PYORRHEA  ALVEOLARIS  AS  A   MARGINAL  GINGIVITIS     657 

It  is  probable  that  the  infecting  agents  in  these  types  differ  in 
their  nature,  or  that  in  the  event  that  they  may  be  proved  to  have 
a  similar  origin  the  tissues  react  differently  to  them,  either  partially 
resisting  them,  forming  calculus  as  a  result  of  the  irritation,  or 
rapidly  giving  way  to  them,  permittmg  a  deep  action.  In  this  con- 
nection it  is  probably  better  that  each  case  be  microscopically  con- 
sidered and  the  local  medicinal  or  systemic  treatment  be  conducted 
in  accord  with  the  findings  and  the  clinical  expressions. 

In  the  abscence  of  known  causes  the  conditions  may  be  divided 
according  to  their  clinical  expressions. 

In  the  consideration  a  pus  flow  due  to  apical  abscess,  lateral  abscess 
upon  a  perforation,  or  that  due  to  obvious  salivary  calculus  (for 
these,  see  under  proper  headings),  also  simple  gingivitis  or  deeply 
seated  gingivitis,  not  resulting  in  the  clinical  feature  of  pyorrhea  as 
defined,  are  excluded. 

PYORRHEA  AVEOLARIS  BEGINNING  AS  A  MARGINAL  GINGI- 
VITIS AND  ASSOCIATED  WITH  SUBGINGIVAL  CALCULUS. 

Causes. — The  causes  of  this  condition  are  those  predisposing  and 
exciting  causes  of  marginal  gingivitis  which  have  been  described. 
(See  page  607.)  Several  local  factors  have  to  be  considered  in  this 
connection:  (1)  The  marginal  infection;  (2)  the  irritative  effects  of 
any  calculus  that  may  be  formed;  (3)  the  deep  infection  by  pyogenic 
organisms;  (4)  the  modification  of  the  progress  of  the  disease  by  the 
attendant  loosening  of  the  teeth  and  death  of  the  pulp. 

Fig.  628 


Case  of  a  boy,  aged  fourteen  years,  with  pyorrhea,  especially  on  lower  anteriors, 
with  hj'pertrophic  gingivitis. 


Clinical  History,  Pathology,  and  Symptoms. — There  is  usually  an 
unclean  condition  of  the  teeth;  infection  exists  either  in  tenacious 
films  of  bacteria  attached  to  the  necks  of  the  teeth  and  requiring 
iodin  disclosing  solution  for  their  detection,  or  in  masses  of  detritus 
readily  noticeable.  Subgingival  calculus  iSj  as  a  rule,  obviously 
present  (Fig.  633). 
42 


658 


PYORRHEA  A LV SOLARIS 


The  gum  margin  may  be  atrophied  or  be  inflamed;  or  it  may  have 
a  fairly  normal  appearance.  When  the  gum  margin  is  pressed  upon, 
pus  may  be  squeezed  out  in  variable  quantity;  even  when  not  apparent 
there  may  be  an  exudate  containing  pus  corpuscles. 

It  is  assumed  that  the  local  infection  brings  about  the  deposit  of 
mucous  exudates  rich  m  calculus  (see  page  632,  for  origm),  at  a  point 
beneath  the  gum  margm,  and  that  formation  of  subgmgival  calculus 
occurs,  followed  by  pyogenic  infection  and  pus  formation. 

The  gum  may  now  be  resorbed  either  with  apparently  normal 
bulk  or  the  margin  may  be  everted  and  thickened  into  a  cord-like 


Fig.  629 


Serumal  calculus,  showing  stalactite-like  formations.     (Talbot.) 


margin  which  is  either  of  normal  color  or  inflamed,  sometimes  there  is 
no  apparent  change  in  the  gmn  margin  or  it  may  be  thin  and  pale; 
the  absorption  of  the  gum  causes  the  exposiu-e  of  the  calculus  (Fig. 
620).  In  this  manner  the  bifurcations  of  the  roots  may  be  uncovered 
and  calculi  be  deposited  in  that  situation.  The  resorption  may  only 
be  confined  to  one  side  of  a  root  and  be  the  result  of  several  successiA'e 
depositions  which  may  remain  when  the  gum  recedes,  or  which  may 
be  removed  and  again  be  deposited.  In  this  way  the  side  of  the  root 
may  be  exposed  nearly  to,  and  in  some  cases  quite  to,  the  apex. 
The  destruction  of  the  tissues  may  assume  several  forms.  In 
certain  mouths,  especially  in  neurasthenic  and  anemic  patients,  a 


PYORRHEA  ALVEOLARIS  AS  A   MARGINAL  GINGIVITIS     659 

viscous  material  may  accumulate  upon  the  necks  of  teeth  or  exposed 
roots;  and  the  pericementum,  bone,  and  gum  may  rapidly  inflame 
and  disappear,  leaving  the  roots  exposed  to  collect  more  of  the 
material,  while  pus  may  not  be  much  in  evidence. 

Fig.  630 


Destruction  of  pericementum,  bone,  and  gum  over  buccal  root  of  a  molar. 
(See  also  Fig.  583.) 

The  resorption  may  occur  as  shown  in  Fig.  031,  or  the  gum  may 
be  split  and  the  destruction  follow  the  length  of  the  root  on  one  side 
only  until  even  the  apex  is  reached  (Fig.  630). 

The  tooth  may  be  loose  or  firmly  attached  by  the  remainder  of  the 
pericementum.  This  is  especially  true  of  those  teeth  having  very 
narrow  necks,  in  which  the  roots  describe  a  prominent  curve  just 
above  the  cervix. 

Fig.  631 


Resorption  of  gum  over  palatal  root  of  an  upper  molar,  associated  with  but  trifling 
deposit  of  calculus,  but  the  root  is  covered  with  a  viscid  deposit.  Aged  thirty-two 
years.  Patient  neurasthenic  and  of  tuberciilous  diathesis.  Condition  in  1904.  Tooth 
lost  in  1907.  In  1912  several  other  teeth  were  lost.  In  1914  several  more  had  gone. 
In  1918  the  last  upper  six  anteriors  removed. 


In  such  cases  the  pus  pocket  may  not  be  deep  and  the  pus  formed 
may  readily  be  washed  away.  Such  cases  present  some  resemblance 
to  simple  gingivitis  and  might  be  so  classed  or  as  periodontoclasia 
if  there  were  no  pus  flow.  Instead  of  this  the  pericementum  may  be 
progressively  destroyed  by  suppm-ation  and  the  gum  margin  remain 
practically  intact.    In  these  cases  the  pus  flow  is  more  abundant,  a 


660 


PYORRHEA  ALVEOLARIS 


deep  pocket  is  formed,  extending  a  third  or  even  two-thirds  or  more 
of  the  length  of  the  root  (Fig.  622).  It.  is  common  to  find  beads 
of  calculus  deposited  along  the  side  of  the  root  and  presumably  of 
senmial  origin.  The  cementum  being  deprived  of  nutrition,  its 
minute  nutritional  openings  or  openings  containing  fibers  harbor 
bacteria  or  the  shreds  of  necrotic  infected  pericementum  may  remam 
on  the  root  surface. 

These  inflammatory  disturbances  necessarily  involve  deeply 
seated  gingivitis  or  infiltration  of  leukocytes  into  the  interstitial 
connective  tissue  of  the  gum.  As  pointed  out  by  Talbot,  resorption 
of  various  kinds  and  at  times  constructive  changes  accompany  such 
an  inflammation.  (See  Deeply  Seated  Gingivitis.)  Endarteritis  is 
also  noted.  All  varieties  of  degeneration  of  the  remaining  tissues  are 
noted  in  advance  of  its  further  progress.    In  the  early  stages  of  the 


Fig.  632 


Pyorrhea  pockets.  Mesial  root  of 
molar  largely  denuded.  Treated  by 
amputation.     fPrice.) 


Section  of  an  upper  incisor,  showing  at 
a,  a,  a  deposit  of  serumal  calculus  within 
the  free  margin  of  the  gum.     (Black.) 


disease  the  probe  usually  fails  to  discover  micovered  alveolar  bone, 
although  it  may  rarely  do  so.  If  not  imcovered  its  loss  is  due  to 
resorption;  if,  however,  necrotic  and  bare  alveolar  bone  be  found,  it 
is  midergoing  a  molecular  necrosis  mider  the  influence  of  the  pyogenic 
organisms. 

In  some  cases  the  pericementum  may  be  destroyed  at  the  cervical 
third  of  the  root,  the  alveolar  process  may  be  resorbed  on  its  inner 
surface,  and  an  accompanying  constructive  irritation  may  cause 
the  deposition  of  bone  upon  the  outer  aspect  of  the  alveolar  process; 
the  gum  margin  is  also  thickened  by  cell  proliferation.  The  con- 
dition imparts  the  appearance  of  hypertrophy  of  the  gum  and  gum 
margin  (Fig.  634).  The  gum  may  recede  from  this  position  and  expose 
the  calculus  yet  remain  pufl'y  and  cord-like  and  even  ragged  forming 
a  convenient  nidus  for  food,  mucus,  etc.,  which  gives  the  part  an 


PYORRHEA  ALVEOLARIS  AS  A  MARGINAL  GINGIVITIS     661. 

angry,  slimy  look.  The  inflammation  of  the  pericementum  may 
become  general  and  the  attendant  swelling  forces  the  tooth  into 
malocclusion  with  its  antagonist.  The  mechanical  factor  is  now 
introduced  and  the  extrusion  increases  gradually  or  even  rapidly. 
Even  if  not  very  much  extruded  looseness  due  to  uiflammation  and 
bone  resorption  begins.  Sometimes  such  teeth  can  be  ground  one- 
eighth  inch  before  removing  the  excess  occlusion.  Such  constant 
pounding  is  deadly.  By  placing  the  finger  over  the  tooth  and  direct- 
ing closure  of  the  jaw  this  malocclusion  will  be  noted  to  cause  "buck- 
ling" or  forcing  of  the  teeth  to  one  side. 

When  about  one-half  or  more  of  the  root  has  been  stripped  of 
pericementum  and  deprived  of  alveolar  support,  looseness  and 
extrusion  of  the  tooth  become  marked. 


Fig.  634 


Fig.  635 


Section  of  an  upper  incisor,  showing 
destruction  of  the  peridental  membrane 
and  aversion  of  the  alveolar  wall,  with 
thickening  of  its  border:  a,  serumal  cal- 
culus; b,  thickened  border  of  the  alveolar 
wall;  c,  pus  cavity.    (Black.) 


Section  of  an  upper  molar  with  its 
alveolus,  etc.,  showing  deposit  of  serumal 
calculus  under  the  gingival  borders:  a,  a, 
serumal  calculus.     (Black.) 


The  advance  of  the  disease  now  becomes  more  rapid;  the  undue 
mobility  and  malocclusion  of  the  tooth  excite  an  inflammatory 
reaction  beyond  the  directly  infected  part;  so  that  soreness  and 
looseness  are  further  increased.  Extraction  at  the  later  stages 
reveals  a  thickened  apical  pericementum  as  the  sole  attachment  to 
the  bone.  After  the  looseness  of  the  tooth  becomes  marked,  the 
pulp  of  the  tooth  undergoes  h;^^eremic  changes,  reacts  to  thermal 
stimuli,  and  often  dies.  Pulp  nodules  often  are  formed  before  its 
death.  Reflex  symptoms  may  occur  at  this  stage  when  the  pus 
pocket  approaches  the  apex.  Hartzell  and  Henrici  claim  that  the  pulp 
may  be  infected  before  the  pocket  reaches  the  apex.  (See  Pulpitis.) 
Infection  of  the  dead  or  practically  dead  pulp^readily  occurs  via 


662  PYORRHEA  ALV SOLARIS 

the  pocket  (see  Fig.  630),  and  apical  suppuration  arises.  The 
symptoms  of  the  latter  condition  are  modified,  according  to  the 
facility  with  which  the  pus  finds  vent  along  the  pyorrhea  pocket. 
(A  true  apical  abscess  or  aggravated  pyorrhea  resulting.)  In  some 
cases  pericemental  abscess  becomes  associated  before  the  apical 
tissues  are  involved.  The  disease  proceeds  until  the  affected  tooth 
or  teeth  are  cast  out,  the  alveolar  walls  having  been  largely  absorbed, 
and  the  pericementum  largely  destroyed.  The  remainder  of  it  is 
usually  swollen.  The  disease  ceases  with  the  loss  of  the  affected  teeth, 
leaving  a  flattened  or  absent  alveolar  ridge  covered  by  a  mass  of  more 
or  less  spongy  gum  tissue,  though  some  cases  of  necrotic  alveolus 
occur. 

The  duration  of  this  disease  may  be  months  or  years,  and  a  number 
of  teeth  may  be  affected  at  once.  A  general  subcatarrhal  condition 
of  the  mouth  usually  attends  the  disease.  The  presence  of  pus 
often  imparts  to  the  breath  a  peculiar,  sweetishly  fetid  odor  which 
may,  however,  be  masked  by  an  odor  of  putrefaction  (pigsty  or 
sewer-gas  odor).  Nasal  catarrh  may  also  be  present  whether  as  a 
cause  or  effect  is  not  proved,  but  it  may  nevertheless  be  a  continuing 
cause  unless  relieved. 

It  is  often  the  case  that  the  shifting  of  pyorrhetic  teeth  due  to 
swelling  of  the  pericementum  permits  them  and  the  other  teeth  to 
move  into  a  position  in  which  they  malocclude.  This  brings  in  a 
mechanical  cause  of  interstitial  gingivitis,  which,  with  the  existing 
infection,  brings  other  teeth  into  the  pyorrhetic  state. 

Diagnosis. — When  a  probe  can  be  passed  for  an  undue  distance 
into  the  gingival  space  and  along  the  root  it  is  well  to  consider  the 
case  one  of  pyorrhea  whether  pus  is  evident  or  not  and  to  institute 
treatment. 

Radiographic  examination  will  frequently  show  apparent  areas  of 
rarefaction  which  are  not  always  pockets  as  deep  as  shown,  but  often 
associated  with  the  beginnings  of  the  disease.  Fig.  637  shows  a  case 
of  a  slightly  loose  left  upper  lateral  in  which  the  pocket  would  seem 
to  extend  nearly  to  the  apex  but  could  not  be  explored  so  deeply. 
Fig.  569  shows  a  somewhat  loose  bicuspid  supporting  a  bridge  and 
overworked.  The  condition  is  the  same,  resorption  of  bone,  but  no 
actual  pocket. 

^The  nature  of  the  infection  can  only  be  determined  by  a  micro- 
scopical examination  (see  page  653). 

Associated  Abscess. — In  a  number  of  cases  of  deep  pyorrhea  pockets 
an  infection  of  the  aveolar  structure,  or,  at  least,  of  the  tissue  remain- 
ing over  the  deepest  portion  of  the  pocket,  may  occur,  and  an  abscess 
form  which  discharges  by  a  fistula  through  the  labial  or  lingual 


PYORRHEA  ALVEOLARIS  AS  A   MARGINAL  GINGIVITIS     663 

aspect  of  the  gum.     It  is  to  be  regarded  as  an  abscess  secondary 
to  a  primary  pyorrhea  alveolaris.     The  passage  of  a  silver  probe 

Fig.  636 


Inflammation  of  pericementum,  endarteritis  obliterans.    Talbot's  case.    (Latham.) 

through  the  two  sinuses  at  once  will  reveal  this  (Fig.  638).     In  a 
tooth  treated  for  apical  abscess  such  a  pyorrhea  pocket  existed,  and 


Fig.  637 


Left  upper  lateral  firm,  but  radiograph  shows  bone  resorption.  A  pocket  could 
only  be  found  on  the  distal  for  about  half  the  apparent  distance.  Practically  no  pus. 
This  patient,  however,  developed  a  pericemental  abscess  at  the  depth  of  a  pocket 
on  the  right  upper  second  bicuspid,  which  I  cured  by  instrumentation. 

doubt  arose  as  to  the  cause.     The  fact  that  it  w^as  near  the  gum 
margin  and  the  probe  could  not  be  passed  into  a  sinus  leading  to  a 


664 


PYORRHEA   ALVEOLARIS 


root-end  was  considered  evidence  of  abscess  secondary  to  pyorrhea. 
Evacuation  and  antisepsis  were  sufficient  to  effect  a  cure. 

In  one  case  of  pyorrhea  alveolaris  of  the  variety  under  considera- 
tion the  pocket  existed  upon  the  mesobuccal  aspect  of  a  right  lower 
third  molar.  The  second  and  first  molars  were  absent.  The  pus 
dissected  away  the  periosteum  of  the  bone  and  formed  a  large  abscess 
over  the  entire  area  of  bone  between  the  third  molar  and  second 
bicuspid.  After  evacuation  of  the  abscess,  the  probe  was  passed 
through  it  to  the  pyorrhea  pocket  (Fig.  639).  A  still  simpler  form  than 
that  shown  in  Fig.  638  has  occasionally  occurred.  The  pyogenic 
organisms  have  burrowed  from  a  gingival  space  normal  in  extent 
into  the  tissue  of  the  free  gingival  margin  forming  a  true  marginal 
abscess.  Another  expression  occasionally  occurs.  The  infection 
travels  via  the  natural  channels  in  the  pericementum  from  the  pyor- 


FiG.  638 


Fig    639 


Gingival  abscess  secondary  to  pyorrhea 
alveolaris:  C,  calculus  in  pyorrhea  pocket; 
F,  fistula  leading  to  pocket  PP;  B,  bone 
on  lingual  side. 


Diagram  of  abscess  secondary  to  pyor- 
rhea alveolaris  (see  text) ;  PP,  pyorrhea 
pocket;  AC,  cavity  of  secondary  abscess; 
B,  bone. 


rhea  pocket  to  a  deeper  point  in  the  pericementum  (for  example,  to 
a  point  one-quarter  inch  or  more  below)  producing  what  is  called  a 
pericemental  abscess  (see  page  698) .  The  tissue  between  may  seem 
unbroken  and  the  fistula  may  seem  like  that  associated  with  chronic 
apical  abscess.  Fig.  640  will  illustrate  the  manner  in  which  this  may 
occur.  In  a  case  of  a  pyorrhea  pocket  on  a  lower  lateral,  transillu- 
mination showed  a  bright  red  spot  at  a  point  a  quarter-inch  below 
the  pocket,  and  to  the  side  of  the  root.  The  pain  was  intense,  and 
only  relieved  by  opening  at  this  point  with  a  lancet.  In  another 
case  a  fistula  appeared  on  the  buccal  gum  about  one-third  inch  above 
the  margin  and  between  the  buccal  roots  of  an  upper  molar.  The 
crown  was  tapped  by  a  student  for  dead  pulp,  but  exposure  of  the 
pulp  demonstrated  its  vitality.  Exploration  showed  a  distolingual 
pyorrhea  pocket  leading  into  the  bifurcation  between  the  distobuccal 


PYORRHEA  ALVEOLARIS  AS  A  MARGINAL  GINGIVITIS     665 

and  lingual  roots.    From  thence  the  pericemental  abscess  discharged 
buccally  between  the  buccal  roots. 

While  dental  caries  may  occur  with  pyorrhea  alveolaris,  it  is  usual 
to  find  the  teeth  of  the  most  highly  organized  structure.  The  pulp 
tissue  is  usually  increased  in  density,  and  there  is  a  tendency  to 
the  constructive  changes,  secondary  dentin,  nodules,  etc.,  and  the 
inevitable  degenerative  changes  following  these^diseases.    This  may 

Fig.  640 


Pericemental  abscess  associated  with  a  pyorrhea  pocket.     (V.  A.  Latham.) 

be  due  to  tooth  movement  which  causes  pulp  stimulation  or  may  at 
times  be  due  to  the  gum  recession  which  exposes  the  cementum. 
This  wearing  away,  the  dentin  is. exposed,  fibrils  are  irritated  and  con- 
structive changes  by  the  pulp  result  in  secondary  dentin  or  nodules 
or  both  (see  pages  359  and  367).  Hypersensitivity  of  necks  is  also 
found  in  some. 

It  has  been  contended  that  these  pulps  are  responsible  in  a  measure 


666  PYORRHEA  ALVEOLARIS 

for  the  pyorrhetic  condition,  but  it  is  now  regarded  as  not  only 
unlikely,  but  that  the  teeth  with  vital  pulps  are  most  amenable  to 
treatment.  The  contrary  process  is  more  than  probable,  as  pyorrhea 
frequently  causes  a  pulp  hyperemia  which  subsides  with  the  cure  of 
the  pocket.     (See  Deeply  Seated  Gingivitis.) 

Prophylaxis. — As  outlined  above,  the  prevention  of  pyorrhea 
alveolaris  of  the  first  class  involves  the  removal  of  the  local  and,  if 
possible,  the  systemic  causes  of  the  gingivitis,  if  any  exists,  and  the 
systematic  cleansing  of  the  teeth  at  short  intervals.  The  daily  use 
of  the  tooth-brush  and  antiseptic  powders  and  washes  by  the  patient 
is  also  important. 

D.  D.  Smith  advises,  for  this  class  of  cases,  a  thorough  cleansing 
once  a  month,  or  at  first  even  oftener.  The  cleansing  is  to  be  done 
with  an  orange-wood  point,  grasped  in  a  Jack  porte-polisher  and 
charged  with  pumice  paste,  best  made  with  hydrogen  dioxid,  or  water 
containing  tincture  of  iodin  or  iodoglycerol.  The  local  sources  of 
gum  infection  are  thus  continually  removed  and  the  gums  stimulated 
by  the  mechanical  irritation  with  the  wood  point.  Bridges  require 
careful  cleansing.     (See  Prophylaxis.) 

Treatment. — The  treatment  of  well-established  pyorrhea  alveolaris 
of  the  first  class  is  to  be  considered  under  three  headings:  (1)  The 
removal  of  pus,  calculus,  and  bacterial  films;  (2)  the  prevention  of 
extreme  mobility;  (3)  the  medicinal  treatment  local  and  general,  the 
prophylaxis,  or  prevention  of  a  relapse  into  the  diseased  condition. 

The  Removal  of  the  Local  Causes. — Calculus  and  the  always 
associated  infection  being  an  obvious  irritant,  they  should  be  removed 
from  crowns  and  all  parts  of  the  roots.  To  prevent  infection  of  sur- 
rounding tissues  and  to  remove  the  pus  present  the  pockets  are  to 
be  flushed  out  with  hydrogen  dioxid,  which  may  be  done  by  means 
of  a  syringe  with  fine  nozzle  after  spraying  out  the  superficial  parts 
by  means  of  an  atomizer  operated  by  compressed  air.  The  forcible 
spray  lifts  away  the  gum  margin  and  cleanses  mechanically  as  well 
as  chemically  though  not  the  depths  of  the  pockets.  The  mouth  is 
reasonably  cleansed  at  the  same  time.  Also  the  use.  of  Talbot's 
iodoglycerol  full  or  quarter  strength  is  a  good  preliminary  germicidal 
treatment.  If  large  quantities  of  supragingival  calculus  exist,  it  is 
well  to  next  remove  the  gross  deposits  and  permit  the  patient  to  use 
an  astringent,  antiseptic  mouth  wash  for  a  few  days,  or  the  operation 
may  be  proceeded  with,  using  trichlorid  of  iodin,  1  to  1000,  as  a 
germicidal  wash. 

Free  bleeding  is  beneficial  to  the  inflamed  tissue.  The  removal  is 
accomplished  with  scalers  of  any  suitable  form,  working  either  with 
push  or  pull  cut  as  best  suits  the  case,  the  latter  being  much  less 


PYORRHEA  ALVEOLARtS  AS  A  MARGINAL  GINGIVITIS     667 

painful,  as  a  rule.  As  a  further  preventive  of  infection  the  writer 
uses  tincture  of  iodin  or  Talbot's  iodoglycerol  picked  up  on  the 
scaler  by  dipping  it  in  a  portion  in  a  minim  glass.  Waas^  uses  as  a 
result  of  bacterial  test  a  1  per  cent,  solution  of  iodin  trichlorid.  He 
found  it  to  kill  cocci  in  fifteen  seconds.  It  may  be  injected  into  the 
pocket.  For  the  purpose  of  disinfecting  instruments  in  passing  from 
pocket  to  pocket  he  wipes  off  the  debris,  passes  it  a  few  times  through 
a  5  per  cent,  solution  of  mercuric  oxycyanid,  washes  in  ethyl  alcohol 
and  burns  off  the  latter.  The  alcohol  and  burning  off  alone  is 
commended  by  Medalia, 

Fig.  641  illustrates  the  method  of  guarding  against  unnecessarily 
wounding  the  soft  tissues.  If  the  calculi  be  extraordinarily  inacces- 
sible the  pockets  may  be  enlarged  by  packing  for  ten  or  fifteen  min- 
utes with  cotton  tampons  saturated  with  the  10  per  cent,  trichlor- 
acetic acid,  which  also  softens  the  calculi,  or  salicylized  cotton  may 
be  left  in  the  pocket  for  a  day  (Black)  or  cotton  may  be  packed  into 
a  deep  pocket  and  soaked  with  20  per  cent,  aqueous  solution  of 
hydrogen  ammonium  fluorid  plus  10  per  cent,  free  hydrochloric  acid 
(see  page  682) .  In  some  cases  novocain  injections  or  applications  of 
powdered  cocain  carried  into  the  pocket  on  the  working  instruments 
must  be  made  to  prevent  excessive  pain,  or  a  mucous  or  conductive 
anesthesia  may  be  resorted  to,  the  teeth  under  its  influence  being 
thoroughly  scaled  and  any  surgical  work  on  the  gums  done.  After 
removal  of  the  bulk  of  calculus  with  scalers  any  fine  granules  gummy 
collections  or  shreds  of  pericementum  should  be  well  rubbed  off 
with  Rhein's  approximal  trimmers,  or  Smith's  pyorrhea  instruments, 
or  the  scalers.  This  removes  the  bacterial  plaques  as  well.  After 
this  medicinal  apphcations  are  made  (see  later).  The  scaling  of 
each  tooth  is  to  be  completed  at  one  sitting,  as  repeated  scalings 
interfere  with  the  regenerative  process,  and  the  pocket  is  most 
accessible  at  that  time,  and,  as  a  rule,  one  thorough  scaling  is  far 
better  than  a  number  of  incomplete  ones.  Several  teeth  may,  how- 
ever, be  done  (note  on  page  684,  Barrett's  method  as  an  exception). 
In  cases  with  deep  pockets  it  is  advisable  to  treat  only  a  few  teeth, 
both  because  of  the  necessary  infection,  but  also  because  much 
general  inoculation  may  result  and  might  cause  metastatic  infection. 
Hartzell  claims  that  if  the  cemental  surface  be  scraped  away  to  the 
depth  of  the  attachment  of  the  peridental  fibers  a  source  of  infection 
lying  in  these  minute  openings  will  be  removed,  and  the  surface  will 
be  left  smooth.2  The  lacunae  of  the  cementum  should  not  be  invaded. 
Barrett  has  shown  that  the  thinnest  possible  histological  preparation 

1  Dental  Items  of  Interest,  March,  1918,  p.  168. 

2  Dental  Cosmos,  1908. 


668 


PYORRHEA  ALVEOLARIS 
Fig.  641 


Showing  the  manner  of  holding  an  instrument  for  detaching  calcareous  deposits 
when  using  the  pushing  motion.  The  third  finger  rests  on  the  edges  of  the  teeth,  allow- 
ing freedom  of  the  hand  to  make  rapid  and  effectual  movements  in  dislodging  the 
calculi.  « 


Fig.  642 


Fig.  643 


Scalers  (three  times  natural  size). 


'  Illustration  of  the  position  and  form  ol 
incision  through  the  gum  for  exposing  the 
root  of  the  tooth  and  injured  alveolar  pro- 
cess: a,  incision.     (Black.) 


PYORRHEA  ALVEOLARIS  AS  A  MARGINAL  GINGIVITIS     669 

of  cementum  ground  from  the  piilpal  side  only  shows  lacunae  present, 
so  that  it  is  probable  that  some  will  be  invaded,  at  least  one  cannot 
say  they  are  not  in  a  practical  case'     (Fig.  645.) 

Fig.  644 


Persistent  flow  of  pus  from  their  gum  margin.    Promptly  checked  and  case   cured  by 

gum  removal. 

The  gum  margins  are  not  to  be  unnecessarily  wounded,  but  very 
redundant  granulations  may  be  cut  away,  and  sometimes  a  soft,  thin 
gum  margin  which  persistently  does  not  become  attached,  but  holds 
pus  bacteria,  should  be  cut  away  to  the  bone  margin,  or  removed 
with  a  cautery.    Gentle  curettement  of  these  soft  tissues  will  excite 


Fig.  645 


Section  of  cementum  ground  from  the  pulpal  side  only,  showing  numerous  lacunce. 

(M.  T.  Barrett.) 

free  bleeding  and  stimulate  granulations,  both  being  desirable.  In  case 
the  pockets  are  so  deep  or  hsive  such  form  that  the  scaling  cannot  be 
done  without  overstretching  or  injuring  the  gingival  edges,  Black  ad- 
vises that  gum  flaps  be  raised,  exposing  the  alveolar  margins  (Fig.  643) . 
A  semicircular  incision  is  made  and  turned  back,  and  bleeding  checked. 
By  means  of  sharp  chisels  the  alveolar  borders  are  freely  scraped,  the 


670 


PYORRHEA  ALV SOLARIS 


pockets  are  flushed  with  hj'drogen  dioxid,  and  the  flap  secured  by  a 
couple  of  stitches  (a  pad  of  cottonoid  wet  with  a  mild  antiseptic  placed 
over  it  serves  as  well).  Local  anesthesia  should  precede  this  opera- 
tion. The  same  writer  advises,  in  cases  where  e version  of  the  alveolar 
margin  has  occurred,  that  the  process  be  exposed  by  cuts  and  broken 
down  by  three  cuts  made  with  a  sharp  chisel  and  mallet;  the  loosened 
segment  of  bone  to  be  pressed  firmly  against  the  root.  It  is  desired 
next  that  the  entire  pocket  will  fill  with  granulation  tissue,  and  organi- 
zation of  the  granulations  take  place,  furnishing  reattachment.  That 
this  occurs  in  some  cases  is  undoubted.  A  good  clot  is  the  best 
occupant  of  the  space.  A  reproduction  of  alveolar  margins  also 
occurs  in  some  cases.  The  hope  of  good  results  lies  in  keeping  the 
parts  reasonably  aseptic  after  all  foreign  deposits  and  dead  material 


Fig.  646 


Fig.  647 


Pyorrhea  pocket  in  bifurcation. 


The  same  treated  by  scraping  and  filling 
with  gutta-percha  or  oxyphosphate  of  cop- 
per.    (Radiographs  by  Price.) 


have  been  removed.  An  exposed  pocket  in  the  bifurcation  may  be 
treated  by  scraping  and  flowing  oxyphosphate  of  copper  cement  into 
it  (Figs.  646  and  647).  In  view  of  hemorrhage  this  may  be  better 
done  if  the  gum  is  gently  packed  away  with  cotton  and  eugenol  for 
a  day. 

In  cases  of  excessive  loss  of  the  pericementmn  to  the  apex  of  one 
root,  the  pulp  will  be  infected  and  must  be  devitalized.  Unless 
markedly  hyperemic  or  evidently  degenerate  it  is  better  not  to  dis- 
turb it  when  the  pocket  does  not  approach  the  apex,  at  least  not  as  a 
routine  measure.  Simple  hyperemia  can  often  be  recovered  from. 
Sometimes  such  a  root  must  be  amputated  if  it  swings  free  of  attach- 
ment, provided  the  other  roots  will  support  the  tooth.  In  view  of  the 
present  doubt  as  to  the  success  of  canal  treatment  it  may  be  better  to 
extract  such  a  tooth. 


PYORRHEA  ALVEOLARIS  AS  A  MARGINAL  'GINGIVITIS     671 

Rhein^  calls  attention  to  the  fact  that  collections  are  apt  to  occur 
about  the  surface  left  by  the  amputation,  and  that  postextraction 
resorption  of  the  alveolar  process  occurs.  To  obviate  this  he  suggests 
the  use  of  a  porcelain  root  to  replace  the  lost  root,  and  about  which 
the  tissues  contract  firmly  and  remain  in  a  healthy  condition.  This 
operation  Rhein  terms  "  heteroplasty  following  the  amputation  of 
natural  roots." 

Briefly  outlined  the  process  is  as  follows; 

1.  Prepare  and  fill  the  root  canals  as  far  as  the  pulp  chamber;  fill 
this  with  temporary  stopping. 

2.  Amputate  the  necrosed  root  by  means  of  a  fissure  drill,  and 
remove. 

3.  Coat  the  root  with  a  film  of  paraffin  to  allow  for  shrinkage  of 
the  porcelain. 

4.  Take  an  impression  of  one-half  of  the  root  (longitudinally)  by 
embedding  in  plaster;  make  articulating  grooves  and  pour  plaster 
for  an  impression  of  the  other  half;  separate  and  remove  the  root 
from  the  plaster. 

5.  Burnish  matrix  platinum  into  each  half  of  the  impression, 
stiffen  with  porcelain,  and  reburnish.  Complete  one  side  with 
porcelain  as  in  inlay  work;  in  the  other  fuse  a  platinum  box  formed 
over  a  square  platinum  pin  (this  pin  should  be  left  in  the  box  until 
the  packing  of  the  porcelain  about  the  box  is  complete). 

6.  Flatten  the  proximating  sides  of  the  halves;  paint  with  thin, 
fresh  body;  press  together  and  fuse. 

7.  Strip  off  all  platinum  and  dress  off  all  protruding  points,  coat 
the  entire  porcelain  with  a  thin  film  of  body,  place  in  furnace  in  an 
upright  position,  and  heat  almost  but  not  quite  to  a  glaze. 

8.  Wash  out  socket  of  natural  root  with  antiseptics  and  remove 
temporary  stopping  from  the  crown  cavity;  try  porcelain  root  in 
place,  and  if  right  dry  everything;  fill  the  box  with  cement,  return 
the  root  to  place,  and  pass  the  pin  through  crown  cavity  and  into  the 
root  box.     Adjust  root,  leaving  a  slight  space  for  an  amalgam  joint. 

9.  Pack  the  crown  cavity  and  the  joint  with  amalgam,  and  at  a 
later  sitting  finish  the  same  (Fig.  648) . 

This  operation  does  not  seem  to  have  general  adoption.  These 
measures  so  far  outlined  together  with  the  grinding  of  maloccludmg 
teeth  and  splinting  for  surgical  rest  constitute  the  so-called  surgical 
method  of  treatment  adopted  by  many  specialists  today,  as  the  sole 
method  of  treatment  and  as  inviting  an  outpouring  of  bone-forming 
material.    Most  of  them  make  a  point  of  extracting  badly  involved 

1  Dental  Cosmos,  September,  1900,  and  Septenaber,  1902. 


672 


PYORRHEA  A LV SOLARIS 


teeth  and  there  is  much  to  be  said  for  this  as  it  removes  the  chief 
som'ce  of  the  infection,  i.  e.,  the  teeth  most  subject  to  recurrence, 
simpHfies  the  treatment  and  enables  supporting  bridges  or  plates, 
acting  as  splints,  to  be  constructed.  In  all  these,  the  demands  of  oral 
hygiene  against  oral  sepsis  are  satisfied  (see  chapter  on  Prophylaxis, 
etc.). 

Some  operators  prefer  to  coat  the  gum  margins  with  a  solution 
composed  of  iodin  crystals  dissolved  to  solution  in  beechwood 
creosote,  following  this  with  a  saturated  solution  of  tannin  in  glycerin, 
these  forming  a  collodion-like  coating  if  applied  with  temporal}^ 
exclusion  of  saliva^  (x4dair,  Hartzell). 

Fig.  648 


Heteroplasty  following  the  amputation  of  natural  roots.     (Rhein.) 

The  Prevention  of  Excessive  Motion. — The  excessive  move- 
ment of  loosened  teeth  but  increases  the  deeply  seated  gingivitis  in 
the  remaining  tissues.  These  demand  rest.  Any  excessive  occlusion 
due  to  the  swelling  of  pericemental  tissue  may  be  compensated  for 
by  grinding  the  occluding  surfaces.  Such  excessive  occlusion  and 
motion  are  readily  detected  diu"ing  the  act  of  occluding  the  teeth 
(by  noting  a  buckling  motion),  or  by  means  of  carbon  paper.  To 
some  extent  retraction  of  the  tooth  may  be  counted  upon  by  con- 
traction of  the  pericementum  in  recovery  due  to  treatment  of  the 
inflammation.  Whether  natural  tightening  up  of  teeth  as  above 
described  may  be  expected  to  suffice  or  whether  splints  must  be 
applied  to  temporarily  aid  in  the  cure  or  whether  the  teeth  should  be 


1  See  I.  Sydney  Smith:  Dental  Cosmos,  I<[Qyembery  1916. 


PYORRHEA  ALVEOLARIS  AS  A  MARGINAL  GINGIVITIS     673 


permanently  fixed  in  position  as  the  only  hope  is  a  matter  for  experi- 
ence, judgment  and  mechanics  to  decide.  Even  trial  of  temporary 
splints  may  indicate  permanent  ones  and  they  should  often  be  con- 
sidered in  the  preliminary  explanation  of  the  treatment  as  they  are 
an  expensive  part  of  the  cure.  The  fixation  of  teeth  is  a  matter  of 
mechanics,  and  the  device  used  depends  upon  the  case.  Slightly 
loosened  teeth  may  be  temporarily  splinted  with  ligatures  of  wire 
or  floss  silk.  To  prevent  the  slipping  of  these  toward  the  gum 
margin  it  has  been  suggested^  that  small  buttons  of  Harvard  or 
other  adhesive  zinc  phosphate  should  be  placed  upon  the  labial  faces 
while  under  the  riibber  dam  (Fig.  649).  The  floss  silk  may  be 
saturated  with  a  solution  of  chemically  pure  celluloid  in  acetone 


Fig.  649 


Fig.  650 


Temporary  splint  of  silk  floss  or  silver  wire  30-gauge  (one  turn  only  shown) .    Buttons 
of  zinc  phosphate.     (Rhein.) 

(155  to  500  gr.2)  to  render  it  impermeable  and  more  lasting.  The 
preparation  after  application  is  allowed  to  dry  under  the  dam  to  a 
coagulum  and  then  dismissed  for  twenty-four  hours,  when  it  may  be 
polished.  It  lasts  for  several  months.  The  wire  should  ordinarily 
be  of  brass,  as  it  is  less  likely  to  permit  caries,  and  may  be  applied 
as  a  single  strand  being  woven  in  figure-of-eight  fashion,  or  better,  a 
single  loop  may  be  made  about  all  the  teeth  to  be  included  and  smaller 
loops  about  the  wire  at  the  interspaces,  and  these  twisted  tight  to 
eftect  a  tightness  of  the  first  wire.  The  fault  in  ligatures  is  that  some 
mobility  is  always  present,  due  to  slipping  and  stretching.  They 
may  slip  toward  the  gum,  in  which  case  a  loop  or  two  may  be  carried 
over  the  occluso-interproximal  embrasm-e.  For  certain  cases  Dr. 
Hugh  Mitchell  has  suggested  a  bar  of  iridioplatinum  wire  adapted 
to  the  lingual  surface  of  the  teeth  to  be  splinted,  and  soldered  to 
simple  gold  bands  to  be  attached  with  cement  to  tM^o  of  the  teeth 
adjoining  the  loose  teeth.  The  other  teeth  are  braced  to  the  splint 
with  fine  wire,  gold  or  platinum  being  prefen-ed  for  anterior  teeth. 


1  Reitz. 


'  Kowarska's  paste. 


43 


674 


PYORRHEA  ALVEOLARIS 


Such  a  splint  may  be  quickly  made  and  is  very  effective,  all  slipping 
of  ligatures  being  prevented;  moreover,  the  wire  may  be  kept  away 
from  the  necks  of  the  teeth  and  the  gums.     It  can  be  used  perman- 


FiG.  651 


Fig.  652 


Diagram  showing  labial  view  of  Mitchell's 
splint,  with  two  bands  and  wiring. 


Diagram  showing  view  of  Mitchell' 
splint  with  two  bands  and  bar. 


ently  (Figs.  651  and  652.)      After  a  reasonable  period  of  immobility 
the  attachment  secured  by  treatment  may  be  tested.     Very  loose 


Fig.  653 


Fig.  654 


Fig.  655 


Five  rings  and  included  artifi-       Two  rings  and  included  artifi-       Method  of  making 
cial  tooth.    (Evans.)  cial  tooth.     (Evans.)  rings  as  in  Fig.  493. 

teeth  which  have  lost  much  of  their  supporting  alveolar  process  must 
be  secured  by  permanent  splints.    The  simplest  of  these  is  a  series  of 


Fig.  656 


Fig.  657 


Labial  view  of  a  splint  (see  text).  Lingual  view  of  splint  shown  in  Fig.  656. 

Fig.  658 


crrrro 

Occlusal  view  of  the  splint. 

rings  soldered  together,  or  its  equivalent,  shown  in  Fig.  650.  The 
teeth  are  firmly  ligated  at  their  necks  with  floss  silk.  A  wire  measure 
is  taken  of  the   entire  circumference  of  the  teeth  to  be  included, 


PYORRHEA  ALV SOLARIS  AS  A  MARGINAL  GINGIVITIS     675 

allowance  being  duly  made  for  burnishing.  A  piece  of  thin  platinum 
or  22  k.  gold,  No.  34  gauge  and  one-eighth  inch  wide,  is  cut  to  measure 
and  a  lap  joint  made  and  soldered.  The  ring  is  placed  upon  the  teeth 
and  moulded  to  their  surfaces  and  to  their  interspaces.  The  thinnest 
separating  saw  is  used  to  cut  almost  through  the  splint  on  both 
sides  at  one  interspace.  In  this  groove  a  straight  piece  of  the  plate 
is  placed  and  the  whole  withdrawn  from  the  teeth  and  the  joints 
soldered.  The  process  is  repeated  at  another  interspace  and  so  on 
until  the  piece  is  complete.  If  the  teeth  are  very  tender,  a  plaster 
impression  of  the  tips  of  the  teeth  may  be  taken  and  the  work  done 
on  a  fusible  metal  model.  It  is  much  less  accurate,  however.  If  space 
be  necessary,  the  teeth  may  be  slightly  disked  upon  their  proximal 
sides.  If  such  spacing  be  not  desirable,  the  necessary  room  can  • 
usually  be  obtained  at  the  median  interspace,  but  one  platinum  sep- 
tum is  placed  and  the  piece  is  to  be  somewhat  stiffened  with  solder 
at  the  indentations  representing  the  interspaces.  To  render  the  appli- 
ance less  conspicuous  the  entire  lingual  side  may  be  stiffened  with 
solder  and  solder  be  placed  liberally  at  the  junction  of  band  and 
septum  on  the  labial  side.  Nearly  all  the  labial  portions  of  the  bands 
except  the  end  ones  may  be  cut  away,  leaving  T-buttons  at  the  labial 
portions  of  the  septa  (Figs.  656  and  658).  The  teeth  may  loosen 
in  this  more  readily  than  in  that  shown  in  Fig.  650. 

Another  valuable  device  consists  in  grinding  steps  into  the  lingual 
surface  of  an  incisor  or  cuspid.  Soft  thin  metal  is  adapted.  Three 
pins.  No.  20  guage,  are  placed,  two  incisal  straddling  the  pulp  and 
one  at  the  cervical  step.  The  whole  is  stiffened  with  solder.  Adjoin- 
ing teeth  may  be  united  by  union  of  these  plates  or  they  may  be 
used  as  anterior  abutments  of  bridges.  A  modification  consists  in 
grinding  the  whole  of  the  lingual  enough  for  strength  and  allowance 
for  occlusion,  using  three  safely  placed  pins  and  allowing  the  plate 
to  grasp  the  mesial  and  distal  slopes  of  the  lingual  surface.  This 
resists  the  twisting  strain. 

It  may  also  be  used  on  centrals  and  cuspids.     For  example,  in 
a   case   of   loss  of   an  upper  cuspid  and  lateral  the  two   centrals 
were  fitted  with  the  tripod  step  plates  in  Fig.  659  and 
the  first  bicuspid  with  a  Carmichael,  the  pontic  teeth       fig.  659 
then  attached.     No  pulps  were  devitalized.     In  bicus- 
pids the  Carmichael  attachment  forms  a  very  strong 
abutment.     For  example,  in  a  case  practical  for  several 
years  two  somewhat  loose  upper  bicuspids  and  a  some- 
what firmer   cuspid  were  splinted  with  attached  Car- 
michaels.     These  must  be  watched  for  possible  subsequent  caries 
•which  is,  however,  not  so  great  as  to  be  prohibitive. 


676  PYORRHEA  ALVEOLARIS 

Evans'  method  is  readily  comprehended  by  reference  to  Figs, 
653,  654,  and  655. 

These  sphnts  are  to  be  cemented  with  adhesive  hydrauhc  zinc 
phosphate  so  manipulated  as  to  set  quickly. 

The  foregoing  splints  are  too  conspicuous  for  use  in  some  cases. 

A  simple  device  introduced  by  Dr.  L.  C.  Bryan^  consists  of  a  pure 
gold  band  about  one-eighth  inch  wide,  nicely  bevelled  at  its  edges, 
and  adapted  about  the  necks  of  the  lower  incisor  teeth  to  be  splinted 
in  somewhat  the  same  manner  that  the  splint  illustrated  in  Fig.  650 
is  adapted.  Particular  attention  is  paid  to  the  interspaces  in  the 
endeavor  to  bring  the  labial  and  lingual  sections  together  as  nearly 
as  possible  at  that  point.  When  ready  the  piece  is  sprung  off,  the 
rubber  dam  is  applied,  zinc  phosphate  is  placed  within  the  band  and 
upon  the  necks  of  the  teeth  at  all  points,  and  the  band  is  put  in 
place  and  burnished.  Before  the  cement  has  set  gold  wire  is  to  be 
passed  around  the  interdental  portions,  tightly  twisted,  and  the 
twisted  end  cut  off  nearly  to  the  band,  and  the  remainder  bent  back 
into  the  indentation  in  the  band.  Dr.  Bryan  recommended  gold 
clamps  in  the  place  of  wire,  but  these  are  difficult  of  adaptation. 

Such  a  piece  is  to  be  placed  only  on  those  lower  incisors  about 
which  salivary  calculus  promptly  collects,  and  should  be  avoided 
in  the  mouths  of  patients  who  will  not  present  frequently  for  pro- 
phylactic service.  Confined  to  such  cases  they  do  good  service,  and 
the  cement  does  not  readily  wash  aw^ay;  indeed,  a  slight  coating  of 
calculus  seems  to  protect  the  surface  of  it  from  solution.  If  the 
calculus  be  kept  from  the  gum  this  remnant  does  no  harm. 

Several  devices  have  been  offered  which  require  the  devitalization 
of  the  pulps  and  filling  of  the  root  canals  of  the  several  teeth  to  be 
splinted. 

D.  D.  Smith^  suggests  reduction  of  the  lingual  surfaces  of  the 
teeth  and  the  fitting  to  them  of  thin  metal  backings,  which,  after 
adaptation  to  the  teeth,  are  perforated  and  pins  are  thrust  through 
for  the  root  canals.  After  soldering  each  pin  to  its  plate,  readapting 
the  latter  and  stiffening  with  solder,  an  impression  is  taken  and  the 
plates  are  united.  The  whole  piece  is  cemented  to  place  with  oxy- 
phosphate.  A  modification  for  vital  teeth  would  be  to  drill  three 
safe  pits  for  pins  for  each  plate  instead  of  the  one  central  pin  for 
the  canal,  or  to  drill  one  hole  through  the  incisal  portion  above  the 
pulp  for  each  plate.  With  this  device  one  or  more  artificial  teeth 
may  be  included  to  replace  lost  teeth  (Figs.  660  to  664).  The 
incisal  edges,  if  broad,  could  have  individual  inlays  cast  on  two 
safely  placed  pins  and  these  soldered  together. 

1  International  Dental  Journal,  1899.  2  Dental  Digest,  1902, 


FiQ.  660 


FiQ.  661 


Splint  for  securing  previously  treated  lower 
anterior  teeth.     (Ames,  after  Smith.) 

Fig.  662 


Splint  for  use  in  the  case  shown  in  Fig.  661. 
Fig.  664 


Same  as  Fig.  661.    Splint  in  position. 
Fig.  665 


Upper  teeth  prepared  for  splint. 
(Ames.) 

Fig.  663 


Root  with  cap  fitted.     (Ames  ) 
Fig.  666 


Tooth  with  Richmond  cap.    (Ames.)       Splint  for  lower  incisors.     (See  text.)    (Ames.) 


678 


PYORRHEA  A LV SOLARIS 


I  had  a  case  of  loose  pyorrhetic  incisors  to  be  splinted  with 
the  pulps  vital  and  an  artificial  tooth  included.  Following  a 
radiograph  two  pits  were  drilled  from  the  Imgual  in  each  incisor  for 
reception  of  iridioplatinum  wire,  No.  20  gauge.  Thin  platinum 
plates  were  adapted  to  each  tooth  and  the  pins  thrust  through  and 
soldered  separately  for  each  pin.  After  readaptation  of  each  plate 
and  stiffening  wdth  22  k.  solder,  they  were  all  placed  in  position  and 
an  impression  taken,  a  fire-withstanding  model  made  and  the  pieces 
united,  a  temporary  wire  looping  lingually  being  used  across  the  space 
for  the  tooth  to  be  introduced.  The  whole  was  then  placed  on  the 
teeth  and  adapted  again.  A  new^  impression  and  bite  were  taken  and 
a  long  pin  facing  with  cast  backing  arranged  and  the  latter  soldered 
in  place.  Allowance  was  made  for  the  facing  to  be  slid  in  after 
setting  the  appliance.    A  Steele  facing  might  have  been  used. 

Ames^  suggests  that  in  certain  cases  of  lower  incisors  the  teeth  be 
devitalized  and  amputation  be  performed  at  the  neck  of  each.  Each 
root  is  then  trimmed  and  fitted  with  a  gold  Richmond  cap  without 
pin  (Fig.  663). 

Fig.  667 


Splint  for  lower  incisors.      (See  text.)      (Ames.) 

Each  natural  crown  is  slightly  trimmed  and  fitted  with  a  gold 
Richmond  cap  with  a  pin  (Fig.  665).  These  two  caps  are  united 
with  wax,  carried  to  the  mouth,  and  adjusted  in  position.  Each  is 
then  carefully  removed,  the  natural  crown  laid  aside  (in  water), 
and  the  gold  sections  invested  and  soldered  together.  The  individual 
parts  are  readjusted  in  the  mouth,  an  impression  taken,  an  invest- 

1  Dental  Cosmos,  1903. 


PYORRHEA  ALVEOLARIS  AS  A  MARGIN AL  GINGIVITIS     679 

ment  made,  and  all  soldered  together.  The  natural  crowns  are  then 
fastened  in  their  prepared  sockets  with  cement,  and  the  piece  is 
cemented  to  place.  Pins  may  be  placed  in  the  roots  if  desired 
(Fig.  666). 

Fig.  668 


Splint  and  double  saddle  bridge  combined.    Front  view.    (Ames.) 

If  desired  the  piece  may  be  further  attached  co  the  adjoining 
teeth  by  means  of  the  lingual  plate  and  pin  (Fig.  667).  The  Ames 
device  would  be  useful  in  cases  in  which  approximal  cervical  caries 
exists. 

It  may  be  stated  that  three  or  four  teeth  fairly  loose  individually, 
when  united  together  may,  as  a  whole,  be  quite  firm. 


Fig.  669 


Fig.  670 


Right  side  of  extension  bridge  shown  in 
Fig.  668. 


Left  side  of  extension  bridge  shown  in 
Fig.  668. 


Ames  claims  that  the  extension  bridge  shown  in  Figs.  668,  669, 
and  670  lasted  for  years  and  was  in  as  good  condition  then  as  at  the 
beginning.  Fig.  668  gives  the  anterior  view.  Fig.  669  that  of  the 
right  side,  and  Fig.  670  that  of  the  left  side.  In  view  of  oral  sepsis 
this  would  not  seem  advisable  and  indeed,  one  should  be  chary  of 
devitalizing  teeth  if  possible  to  avoid  it. 


680  PYORRHEA  ALV SOLARIS 

Rhein  offers  the  following:  After  pulp  removal  and  root  filling  a 
transverse  groove  is  cut  in  the  lingual  side  of  the  central  or  loose 
teeth  and  a  half-groove  upon  the  mesiolingual  aspect  of  the  pier 
teeth.  A  staple  is  formed  of  triangular  iridioplatinum  wire  to  fit 
into  the  root  canals  of  the  pier  teeth.  To  this  is  soldered  a  pin  for 
each  of  the  central  teeth.  The  face  of  the  wire  should  approximately 
fit  the  bottom  of  the  groove  (Fig.  671).  Rhein  suggests  the  following 
method  of  attachment:  (1)  Fill  the  root  with  a  paper  point,  place 
cement  over  that,  and  fill  the  cervical  margin  of  the  cavity  and  its 
floor  with  gold;  (2)  drill  through  the  gold  to  the  paper  point,  remove 
it,  and  refit  the  retaining  appliance;  when  ready  set  with  zinc  phos- 
phate, avoiding  excess;  (3)  when  this  is  set  cut  away  to  the  gold 
and  complete  the  gold  fillings. 

A  less  elegant  but  still  practical  method  would  be  to  cover  the 
pins  with  a  good,  color-keeping  amalgam  pressed. into  the  excess  of 
cement  before  it  has  set.  The  margins  are  then  to  be  freed  of  cement 
and  the  operation  completed  with  amalgam,  which  later  should  be 
polished.  In  undecayed  teeth  this  has  no  advantage  over  the  method 
shown  in  Fig.  660;  nor  in  decayed  teeth  over  that  in  Fig.  665. 

Smith's,  Rhein's,  and  Ames'  devices  permit  the  use  of  an  artificial 
tooth  if  necessary.  The  same  may  be  said  for  the  device  which 
consists  of  a  series  of  gold  rings  (Evans'). 

For  the  molars  and  bicuspids  Rhein's  device  is  transferred  to  the 
occlusal  surface  (Fig.  673). 

Short  metal  caps  made  for  the  incisal  tips  of  lower  incisor  teeth 
adjoining  a  space  will  successfully  hold  a  bridge  tooth.  The  device 
is,  however,  rather  conspicuous.  Well  anchored  gold  inlays  joined 
by  solder  or  cast  together,  or  a  staple  in  two  or  more  roots  of 
different  teeth  about  which  staple  fillings  are  later  built  may  be 
useful.     Carmichael  attachments  will  serve  for  some  teeth. 

For  the  molar  and  bicuspid  teeth  it  seems  good  practice  to  adapt 
short  crowns  to  the  teeth  trimmed  only  to  the  fullest  point  of  con- 
tour, and  unite  these  with  solder.  Occasionally  the  bands  may  be 
slit  occlusally  and  adapted  closely  without  covering  the  cusps.  A 
sort  of  bridge  is  thus  made  which  causes  the  teeth  to  be  firm  even 
if  all  are  originally  loose  (Fig.  672) .  It  is  mainly  this  factor  which 
renders  bridge-work  useful  in  pyorrhea  alveolaris  upon  isolated 
teeth.  If  the  necks  of  such  teeth  are  hypersensitive,  silver  nitrate  may 
be  used.  This  device  is  especially  useful  when  teeth  are  inclined. 
As  an  example,  an  upper  third  and  second  molar  were  fitted  with 
short  crowns,  a  first  bicuspid  with  a  Carmichael  and  a  pontic 
bicuspid  used.     These  united  held  the  three  loose  teeth  very  firmly. 

The  use  of  united  barrel  crowns  reaching  the  gum  margins  is  at 


PYORRHEA  ALVEOLARIS  AS  A  MARGINAL  GINGIVITIS     681 

times  useful,  but  the  configuration  of  exposed  roots  may  render  this 
impossible  in  some  cases. 

By  the  use  of  pure  gold  crowns,  which  may  be  stiffened  occlusally 
with  solder  to  gain  strength,  or  a  22  k.  reinforced  occlusal  used,  or  a 
specially  stamped  clasp  metal  occlusal  used,  better  adaptation  at 
cervical  portions  may  be  obtained  by  hand  burnishing  after  cemen- 
tation of  the  piece. 

All  appliances  cemented  to  the  teeth  and  having  a  free  margin  are 
'subject  in  some  degree  to  a  solution  of  the  cement.  These  cases 
should  be  seen  frequently  in  any  event  for  prophylactic  purposes, 
when  the  condition  of  the  appliance  may  be  noted. 

Extraction  and  bridge-work  may  be  at  once  resorted  to  in  some 
of  the  aggravated  cases,  though  if  the  appliance  be  mechanically 
constructed  teeth  which  may  be  extracted  with  the  fingers  may  be 
firmly  held  in  splints  for  years.  While  this  is  a  fact,  good  judgment 
as  to  sepsis  demands  the  early  removal  of  such  teeth  before  an  appli- 
ance is  constructed. 

If  desired  the  bridge  may  be  made  so  as  to  mount  the  natural  teeth 
after  their  extraction,  by  constructing  sockets  of  gold  for  the  recep- 


FiG.  671 


Fig.  672 


Permanent  splint  for  cases  of  pyorrhea  alveo- 
laris  in  upper  or  lower  incisors.     (Rhein.) 

Fig.  673 

tion  of  the  necks  of  the  teeth 
somewhat  after  the  manner 
employed  in  the  Amesmethod. 
The  sockets  are  then  soldeerd 
to  each  other  and  to  the 
bridge  piers,  after  which  the 
teeth  are  attached. 

These  sockets  are  to  be 
made  deep  at  first,  and  it  is 
well  to  attach  the  teeth  with  gutta-percha  in  order  that  the  row  of 
sockets  or  a  new  row  may  be  lowered  to  fit  the  gum  if  desirable.  This 
will  require  the  raising  of  the  teeth  to  the  occlusal  level.  Occasionally 
the  use  of  the  overarch  bar  is  demanded  to  prevent  the  overuse  of  the 
teeth  acting  as  piers  for  bridge-work. 


Permanent  splint  for  cases  of  pyorrhea  alveo- 
laris  on  molars  and  bicuspids. 


682  PYORRHEA  ALVEOLAktS 

E.  Ewing  Roach^  has  suggested  that  in  case  of  loose  incisors  drill 
holes  may  be  made  from  mesial  to  distal  or  the  reverse,  and  a  plati- 
num wire,  18  or  20  gauge,  be  cemented  through  the  several  teeth. 
The  cases  must,  of  course,  be  selected. 

The  lateral  support  of  teeth  by  plates  is  occasionally  of  use  in 
pyorrhea,  but  the  question  requires  careful  consideration.  (See 
page  591.)  The  prevention  of  mobility  in  advanced  cases  may  be 
at  times  an  impossibility.  In  such  cases  extraction,  and  the  use  of 
artificial  teeth  or  of  bridges,  is  probably  better  judgment  than  the 
retention  of  the  teeth  mitil  extracted  one  by  one.  In  all  cases  the 
element  of  overuse  must  be  considered  and  anything  possible  done 
to  prevent  it.  (Read  carefully  pages  588  to  593.)  Also  anythmg 
that  may  induce  gingivitis,  as  a  riding  plate  festoon,  must,  if 
possible,  be  avoided. 

Medicinal  Treatment. — Simple  cases  often  heal  spontaneously  after 
thorough  work  and  antisepsis.  If  aseptic  a  clot  drawn  after  the  irri- 
gation of  the  pocket  with  hydrogen  dioxid  is  often  useful.  Some 
operators  depend  upon  blood  flow,  the  calculus  being  fished  out  with 
clot  as  the  work  proceeds.  In  order  to  control  the  patient  and  watch 
the  case,  any  pocket  existing  after  a  w^eek  should  be  washed  out  with 
hydrogen  dioxid  and  then  filled  with  balsam  of  Peru  which  can  be 
kept  ready  at  hand  in  a  Safety  Sub.  Q  syringe.  This  substance  is  a 
mild  antiseptic  stimulant  of  a  viscidity  sufficient  to  fill  the  pockets 
even  though  wet,  if  the  needle  is  inserted  to  the  bottom.  Thereafter 
it  should  be  used  twice  a  week. 

If  the  case  refuse  to  heal  there  may  be  calculus  overlooked  upon 
the  roots.  An  acid  is  used  to  soften  this  if  not  removable  by  instru- 
ments. Head  recommends  the  use  in  the  pockets  on  each  fourth 
day  of  ammonium  bifluorid-  as  a  solvent  of  calculus  and  tissue 
stimulant.  It  does  not  dissolve  enamel  or  cementum.  The  tissues 
are  to  be  protected  against  burns  from  any  overflow,  which  must  be 
removed.  It  produces  no  harm  within  two  minutes.  It  is  to  be 
injected  with  a  rubber  syringe  with  a  platinum  point  (Dunn  syringe) . 

Lactic  acid  full  strength  (Younger),  trichloracetic  acid,  25  per 
cent,  strength  (Kirk) ;  sulphuric  acid,  25  per  cent,  strength  (Truman) 
are  all  solvent  for  tartar,  and  stimulant  germicides  if  infection  con- 
tinues the  ulceration.  The  applications  are  made  once  or  twice  a 
week  until  suppuration  ceases  and  the  pockets  are  closed. 

1  Dental  Cosmos,  1908,  p.  65. 

2  "Tartar  Solvent,"  or  "Tartasol,"  is  made  by  neutralizing  hydrofluoric  acid  with 
ammonium  carbonate,  filtering,  evaporating  to  half  the  bulk,  adding  again  an  equal 
bulk  of  hydrofluoric  acid,  and  again  evaporating  to  one-half  bulk  (at  90°  to  105°  F.). 
(Items  of  Interest,  1909,  p.  175.) 


PYORRHEA   ALVEOLARIS  AS  A  MARGINAL  GINGIVITIS     683 

As  an  astringent  antiseptic  zinc  chlorid  deliquesced,  or  sulpho- 
carbolate  of  zinc  in  10  per  cent,  solution,  or  zinc  iodid  in  10  per  cent, 
solution,  or  copper  sulphate,  10  per  cent.,  or  powdered  copper  sul- 
phate are  all  useful. 

As  an  astringent  lotion,  zinc  chlorid,  gr.  x  to  each  fluidounce  of 
aquae  rosse,  aquse  gaultherise,  aquae  menthi  piperitse,  etc.,  may  be 
applied  by  the  patient  daily  on  a  cotton  swab  made  by  rolling  cotton 
on  the  end  of  a  tooth  pick.  It  may  be  diluted  to  an  agreeable  astrin- 
gence  for  a  mouth  wash  (or  two-minute  bath),  or  tincture  of  iodin 
may  be  applied  every  other  day,  or  iodoglycerol  (see  page  678)  may 
be  painted  upon  the  gums  every  other  day  b}-  the  dentist,  iodoglycerol 
diluted  1  to  3  with  water  may  be  applied  daily  by  the  patient  or  may 
be  diluted  1  to  500  as  a  wash. 

Gentle  massage  of  the  gums  by  means  of  the  finger-tips  stimulates 
the  tissues  and  squeezes  out  secretions.  If  common  table  salt  be 
used  in  conjunction  the  stimulant  antiseptic  effect  is  obtained. 
Powdered  sulphur  is  recommended  by  Gordon  White  instead. 

The  use  of  a  strong  stream  of  water  from  a  syringe  is  recommended 
by  Black  to  wash  away  the  agglutinin  collected.  His  use  of  this 
alone  has  been  condemned  by  experienced  periodontitists. 

Dr.  A.  B.  Harrower  has  suggested  the  following  formula  for  a 
powder  which  has  in  his  own  and  my  hands  given  good  results  as  an 
astringent  antiseptic: 

I^ — Magnesium  carbonate lb.  j 

Cream  of  tartar lb.  iss 

Red  cinchona  bark gij 

Calcined  alum gj 

Oil  peppermint '    .  f3v 

Oil  cinnamon f  §iii 

Oil  rose  geranium f  3J 

All  ingredients  to  be  finely  powdered.  The  oils  are  to  be  added  to  the  magnesium 
before  thorough  mixing  of  the  powders.    The  whole  is  to  be  sifted  through  silk. 

Saccharin  may  be  added  to  the  above  as  a  sweetening  agent.  The  powder  when 
wet  is  almost  neutral,  and  should  do  no  harm  in  its  limited  use  as  a  therapeutic  agent. 
I  have  also  had  good  results  from  the  alternate  use  of  Pepsodent  Tooth  Paste  as  a 
cleanser  and  Pyorrhocide  Tooth  Powder,  especially  if  a  special  brush  made  from  a 
pointed  polishing  brush  held  in  a  Jack  porte  polisher  is  occasionally  used.  (See  Pro- 
phylaxis.) 

Black  has  recommended  the  use  of  the  1-2-3  mixture,  or  phenol- 
camphor,  to  be  put  into  the  pockets  every  three  days,  and  a  few 
drops  to  be  used  on  the  tooth  brush. 

I^ — OU  of  cinnamon 1  part 

Carbolic  acid 2  parts 

Oil  of  gaultheria 3  parts 

I^ — Gum  camphor, 

Crystal  carbolic  acid     .      ; -    aa     q.s. 

Mix  in  a  mortar  to  an  oily  fluid. 


684  PYORRHEA  ALVEOLARIS 

Barrett^  injects  as  an  amebacide  in  cases  showing  endamoebse  a 
one-half  of  1  per  cent,  solution  of  emetin  hydrochlorid  in  normal 
saline  solution  into  the  tissue  at  the  bottom  of  a  pocket  and  fills  the 
pocket  with  the  solution,  repeating  this  on  several  consecutive  days  (see 
page  712).  The  scaling  is  not  all  done  on  each  tooth  at  once  by  him, 
but  repeated  on  the  successive  days.  He  finishes  the  treatment  with 
1  per  cent,  iodin  in  normal  sodium  chlorid  solution  as  a  bactericide. 

The  solution  must  be  freshly  made  and  limited  to  |  grain  at  each 
treatment  to  prevent  nausea.  He  agrees  to  hypodermatic  treatment 
with  Emetin  at  the  end  of  the  course  to  reach  unknown  foci.  If 
complicated  with  spirochetal  infection  treat  locally  with  some  one 
of  the  arsenical  preparations,  as  neosalvarsan  or  arsenobenzol. 

Regeneration  in  the  pockets  should  not  be  disturbed,  so  that 
unless  the  pus  flow  be  active  one  should  wait  until  sufficient  time  has 
been  afforded  (about  a  week  or  ten  days)  for  granulations  to  form. 
If  pus  be  then  detected  the  pocket  should  be  again  treated  thoroughly. 
Good  results  are  obtained  from  the  use  of  an  astringent  antiseptic 
wash  used  in  forcible  spray  from  an  atomizer  or  introduced  by  means 
of  a  syringe.  This  should  be  done  daily  by  the  patient.  (See 
Asepsis.)  Stagnant  fluids  in  the  pockets  are  washed  out  and 
replaced  by  the  antiseptic,  thus  inhibiting  the  bacterial  growth  in 
the  pockets  and  the  mouth. 

The  teeth  should  be  cleansed  after  meals  to  prevent  media  for 
infection  lodging  about  the  interstices,  after  which  the  antiseptic 
spray  will  aid  in  inhibiting  bacteria.  If  the  case  still  refuse  to  heal 
Beck's  bismuth  paste  may  be  used. 

IJ — Bismuth  subnitrate 30  parts 

White  wax .5  parts 

Paraffin 5  parts 

Vaselin 60  parts 

Mix  while  boiling. 

It  is  injected  from  a  syringe  kept  for  the  purpose. 

Good  results  from  the  application  of  the  x-rays  and  high-frequency 
currents  have  been  claimed  by  Parker,^  Price,  Guy,  Satterlee,  Tousey, 
and  others. 

Raper  claims  that  the  otherwise  incurable  cases  are  not  beneflted, 
and  there  is  also  some  danger  in  repeated  applications  of  .r-rays. 

Sturridge^  has  shown  that  antiseptic  ions  may  be  introduced  into  the 
overlying  gum  tissue  to  the  depth  of  4  mm.  with  5  ma.  of  electrolytic 
current  in  three  minutes.    He  favors  3  per  cent,  zinc  chlorid  solution 

1  Dental  Items  of  Interest,  1915. 

2  Dental  Cosmos,  December,  1903. 

3  Ibid.,  1916,  p.  403. 


PYORRHEA  ALVEOLARIS  AS  A  MARGINAL  GINGIVITIS     685 

and  3  to  15  ma.  positive  pole  in  the  gum  trough  as  checking  pus 
formation  and  improving  the  tone  of  the  tissues,  when  conjoined 
with  the  approved  mechanical  treatment  as  previously  outlined.  He 
notes  the  disappearance  of  alimentary  toxemia,  toxic  neurasthenia, 
rheumatism,  arthritis,  etc.,  under  this  treatment  as  a  result  of  cure 
of  pyorrhea  when  dependent  upon  it.  Fette  claims  good  results 
from  the  use  of  a  small  copper  spatula  positive  electrode,  used 
without  any  liquid,  for  the  purpose  of  introducing  copper  ions  until 
the  tissues  are  colored  blue. 

The  high-frequency  currents  are  applied  by  small  vacuum  tubes 
or  electrodes  directly  to  the  gums.  They  contain  and  emit  violet 
and  ultra-violet  rays,  which  not  only  stimulate  the  part  through  the 
electricity,  but  also  produce  ozone  upon  the  gum  surface  and  carry 
it  in  and  also  produce  ozone  in  the  tissue  by  electrolysis. 

The  production  of  Bier's  hyperemia  by  suction  upon  the  tissues 
is  attributed  to  Keefe^  by  Cazier.  Prinz  and  Colyer  also  recommend 
it.  Cazier  has  introduced  a  method  of  general  suction  by  means  of  a 
rubber  cup  somewhat  like  an  impression  tray,  having  a  tube  attached 
to  fit  over  the  entire  arch  and  alveolar  gums.  A  vacuum  is  created 
by  means  of  a  suction  apparatus  attached  to  a  water  faucet  and 
operating  like  a  saliva  ejector,  a  rubber  tube  and  a  secretion  catching 
bottle  are  the  connecting  media.  It  is  known  as  the  "Sanitor." 
The  strong  vacuum  to  be  made  daily  evacuates  the  infected  secre- 
tions in  the  pockets,  and  induces  a  flow  of  healthy  secretions,  and 
induces  a  hyperemia  increasing  the  opsonic  index  of  the  fluids  of 
the  tissues  and  the  number  of  healthy  phagoc}'tes. 

The  cups  sold  sometimes  do  not  fit,  especially  with  long  teeth. 
The  writer  then  takes  a  modelling  compound  impression,  makes  a 
model  (Fig.  674),  builds  the  teeth  up  with  plaster,  but  keeps  it  away 
from  the  parts  representing  the  gums  to  be  covered.  Over  this  while 
warmed  a  broad  sheet  of  Para  vulcanizable  rubber^  is  adapted  with  the 
fingers  and  an  extra  layer  placed  where  stiffening  is  required  (not  at 
the  flanges).  A  tube  is  inserted  in  place  and  the  whole  vulcanized 
for  thirty-five  minutes  at  317°  F.  A  box  flask  may  be  necessary. 
This  is  to  be  used  by  the  patient  twice  a  day  at  the  beginning,  once 
a  day  later,  then  perhaps  every  two  or  three  days  as  a  prophylactic. 
Good  results  have  been  obtained  in  some  cases  by  extraction  and 
replantation,  after  root  preparation  and  sterilization  of  the  tooth  and 
alveolus.  The  alveolus  may  have  to  be  deepened.  The  method  is 
open  to  question. 

There  sometimes  appear    pus   pockets  or    periodontoclasia  with 

1  Dental  Items  of  Interest,  December,  1916,  p.  927. 

2  Obtainable  of  the  S.  S.  White  Dental  Mfg.  Co, 


686 


PYORRHEA  ALVEOLARIS 


or  without  pocket  on  a  few  teeth  in  mouths,  that  while  attended  to 
have  gradually  gone  through  poor  operative  procedures,  especially 
such  as  are  due  to  extractions  or  poor  contours.    These  should  be 


Fig.  674 


Very  persistent  case  of  pyorrhea,  in  a  young  man,  aged  twenty-five  years,  apparently 

vigorous. 

looked  after  and  the  mechanical   conditions  corrected.     They  are 
sometimes  more  annoying  than  new  and  frank  cases  of  pyorrhea. 

Prophylaxis.- — This  is  all-important,  especially  in  the  cases  in  which 
chronic  disease  or  malnutrition  may  not  be  readily  overcome  owing 

Fig.  675 


Method  of  building  up  the  model  in  Fig.  674  with  plaster;  ready  for  covering   with 

■\iilcanite. 


to  confirmed  habit  of  life  or  advanced  stage  of  disease.  The  local 
conditions  existing  even  after  a  cure  of  pyorrhea  are  such  as  to  invite 
reinfection,  and  the  establishment  of  microbic  plaques,  which  frequent 


PYORRHEA  ALVEOLAR! S  AS  A   MARGINAL  GINGIVITIS     687 

cleansing  of  the  teeth  will  remove.  The  system  of  monthly  or,  if 
necessary,  more  frequent  prophylaxis  advocated  by  D.  D.  Smith 
should  be  practised.  Its  good  results  are  particularly  manifest  in 
this  class  of  cases.  Also  the  use  of  the  prophylactic  stick  or  brush 
by  the  patient  twice  a  week  and  the  careful  and  proper  use  of  floss 
is  very  beneficial.  The  patient  performs  these  manipulations  with 
difficulty,  and  is  apt  to  backslide.     (See  Prophylaxis.) 

Recurrence  of  the  condition  is  probable  if  the  oral  prophylaxis  or 
systemic  treatment  be  neglected.  The  simpler  cases  yield  quite 
readily;  the  advanced  ones,  in  which  much  of  the  alveolar  process 
is  lost,  and  especially  when  the  gums  are  flabby  and  admit  food  to 
the  pockets,  tax  the  patience  of  operator  and  patient  alike,  and  are 
apt  to  end,  sooner  or  later,  in  loss  of  the  teeth  affected. 

Fig.  676 


Sho"wing  flexible  cap  and  its  tube  for  connection  with  suction  apparatus.     Vulcanized 

over  model  in  Fig.  675. 

This  fact,  however,  should  not  prevent  the  retention  of  these 
teeth  by  every  means  at  command  during  the  period  for  which 
they  may  be  made  useful.  If,  however,  any  tooth  prove  an  incurable 
source  of  pus  formation,  or  from  the  first  be  Hkely  so  to  do,  it  should 
be  removed,  otherwise  the  remaining  teeth,  and  possibly  the  patient's 
blood,  are  continuously  infected. 

Summary  of  Treatment. — It  is  not  expected  that  one  will  employ 
all  the  methods  here  outlined,  but  the  following  routine  may  be 
employed : 

1.  Sterilization  by  sprays  or  especially  Talbot's  iodoglycerol  with 
resterilization  of  instrument  and  pockets  by  using  the  quarter 
strength  iodin  on  the  scaler   as   one  sca,les.     No  serious  objection 


688  PYORRHEA  ALVEOLARIS 

attaches  to  the  use  of  local  anesthetics  if  needed  to  a\^oid  pain  though 
usually  not  needed. 

2.  Thorough  scaling  of  such  teeth  as  are  operated  upon,  removing 
all  particles  from  the  pockets  and  inducing  a  final  clot. 

3.  Keeping  the  parts  aseptic  and  constringed  by  use  of  Talbot's 
iodin  quarter  strength  applied  on  swabs  by  the  patient  and  the  use 
of  the  same  well  diluted  as  a  general  wash. 

4.  The  continuance  of  the  treatments  upon  other  teeth  with 
reattention  to  the  first  pockets,  if  not  healed  after  say  ten  days, 
especially  if  suppurative. 

5.  The  use  of  medicament  in  the  pockets,  if  preferred  or  needed. 
Systemic  treatment  in  bad  cases. 

6.  Attention  to  the  prophylaxis  by  the  patient  and  periodic  pro- 
phylactic treatment  as  needed. 

If  preferred  one  may  take  up  another  technic,  Barrett's,  for  example, 
first  making  the  microscopic  diagnosis  and  pursuing  this  line  of 
thought  tlu-oughout  then  following  up  the  cure  by  prophylaxis 
against  recurrence. 

Systemic  Medication.— Various  methods  of  systemically  attacking 
the  infection  existing  in  the  tissues  about  a  pyorrhea  pocket  have 
been  introduced. 

These  aim  to  either  (1)  destroy  the  bacteria  or  endameba?  by 
introducing  into  the  blood  in  various  ways  certain  antagonistic 
chemical  substances  which  shall  finally  find  their  way  to  the  tis- 
sues involved  and  there  act  as  amebicides  or  bactericides.  (2)  To 
constringe  the  tissues  thus  reducing  their  volume  and  amomit  of 
liquid,  thus  probably  increasing  the  phagocytic  power.  (3)  To  raise 
the  general  leukocytic  count  and  probably  the  opsonic  index,  or  to 
stimulate  phagocytic  actiA'ity  through  the  opsonins  by  means  of 
vaccines.  (4)  To  raise  the  standard  of  health  by  counteracting  morbid 
nutritional  processes  thus  increasing  resistance,  improving  the  quality 
of  blood  and  its  leukocytic  activity  and  probably  its  opsonic  power. 

These  objects  will  be  considered  serially  as  Xos.  1,  2,  3  and  4. 
Object   No.  1. — Three   methods   are   under   consideration  at   the 
present  time: 

(a)  The  use  of  emetin  as  antagonistic  of  endameba^  (buccalis  or 
Kartulisi).  The  hypodermic  injection  of  emetin  hydrochlorid  was 
introduced  by  Bass  and  Johns^  following  the  local  use  by  Barrett, 
and  the  suggestion  by  Smith  of  the  possible  use  of  h^-podermic 
medication  and  both  based  upon  the  demonstration  by  Rogers  of  its 
value,  hj-podermically  against  amoeba  hystolytica  m  the  alimentary 

1  Text-book  on  Alveolodental  Pyorrhea. 


PYORRHEA  ALVEOLARIS  AS  A  MARGINAL  GINGIVITIS     689 

canal  (amebic  dysentery).  They  employ  the  following  technic:  A 
sealed  ampoule  containing  |  grain  in  sterile  solution  is  broken  at  the 
neck  and  the  contents  drawn  into  a  sterile  hypodermic  sjTinge.  A 
point  over  the  insertion  of  the  deltoid  muscle  (or  wherever  the  skin 
is  loose)  is  sterilized  with'pure  lysol  applied  on  moist  (not  wet)  cotton 
on  an  applicator  and  the  injection  made  fairly  deeply  and  intra- 
muscularly or  well  beneath  the  skin.  The  needle  is  w^ithdrawn  and 
the  lysol  wiped  off.  This  is  done  for  six  consecutive  days.  Redness, 
soreness,  itching,  some  possible  formation  of  small  vesicles,  shedding 
of  epithelium  are  probable  or  possible.  Some  luticaria,  usually  mild, 
in  about  1  per  cent,  of  cases. 

They  expect  endamebse  to  disappear  from  the  tissues  in  about  three 
to  six  days  from  the  initial  injection.  Eisen  and  lyj^  report  good 
systemic  results  as  well  as  local  by  a  coursd  of  I  grain  injections  for 
six  consecutive  days.  Local  treatment  follows.  A  second  course 
after  a  week  or  two  is  given  if  endamebse  are  still  present  and  pro- 
phylactic injections  at  a  later  date. 

Alcresta  Ipecac— A  tablet  has  been  prepared  by  Eli  Lilly  &  Co., 
each  containing  the  alkaloid  of  10  grains  of  ipecac  held  in  adsorption 
in  a  colloidal  form  of  hydrated  aluminum  sUicate  to  render  it  insol- 
uble in  the  acids  of  the  stomach,  but  set  free  in  the  alkaline  juices 
of  the  intestines.  The  chances  of  nausea  are  reduced  though  some 
piu-gative  action  ensues'  (Lloyd) .  Emetin  is  absorbed  into  the  blood. 
Bass  and  Johns  accredit  it  with  causing  disappearance  of  endamebse 
from  the  pyorrhea  pockets  about  as  quickly  as  the  hj'podermic 
method. 

Three  tablets  are  given  three  times  a  day  until  about  40  are 
taken. 

(b)  The  Use  of  Succinamide  of  Mercury.- — Dr.  Barton  S.  Wright,^ 
Surgeon,  U.  S.  N.,  in  1910  introduced  the  above  preparation,  to  be 
injected  intramuscularly  preferably  into  the  buttock  by  means  of  a 
BiuTOUghs  and  Welcome  40  m.  all-glass  intramuscular  type  syringe, 
with  Ij  inch  needle.  No.  26  platinum  iridium.  Each  i  grain  tablet  is 
dissolved  in  4  mils,  of  water. 

The  dosage  is  f  gr.  or  |  gr.  initial,  followed  by  |  gr.  or  ^  gr.  seven 
days  later  or  f  gr.  if  idiosyncrasy  appears;  women  require  |  gr.  or  f 
gr.  less  per  dose. 

The  buttock  is  painted  with  iodin  and  allowed  to  dry.  The  needle 
is  held  by  the  hub  between  the  thiunb  and  forefinger  about  a  foot 
above  and  quickly  thrust  to  the  hub  into  the  gluteal  muscle  practi- 
cally without  pain.     The  syrmge  filled  with  the  deshed  solution  is 

1  bental  Items  of  loteiest,  February,  1916,  p.  103. 

2  Dental  Cosmos,  September,  1915,  p.  1004. 

44 


690  PYORRHEA  ALVEOLARIS 

attached  and  a  steady  injection  made,  the  needle  withdrawn  and  the 
pmictiire  touched  with  iodin.^ 

Uniform  improvement  and  cure  of  pyorrhea  and  its  systemic 
sequelae  is  claimed  when  local  measures  are  also  used  which 
Ivritchersky  and  Seguin^  confirm. 

(c)  TJie  Use  of  Neosalvarsan. — Kritchersky  and  Seguin  inject  in- 
travenously 10  to  30  centigrams  of  neosalvarsan  and  claim  their  dis- 
appearance when  spirochetes  are  present  in  pockets  as  is  usual,  with 
good  results  when  local  measures  and  prophylaxis  are  conjoined  (see 
page  654).   In  s^^^hilitic  cases  Wright  also  uses  this  for  the  arthritis. 

^Mien  contra-indicated  they  use  succinamid  of  mercury  as  above. 

Object  No.  2. — ^This  is  accomplished  by  the  use  of  vasoconstrict- 
ing  agents,  especially  dilute  sulphuric  acid,  in  doses  of  15  to  20 
drops  per  orem  three  timfes  a  day  as  long  as  needed. 

Object  No.  3. — (a)  Waas^  has  suggested  the  aseptic  injection  sub- 
cutaneously  of  2  mils,  of  a  10  per  cent,  solution  of  sodium  nuclein  salt 
in  phj'^siological  salt  solution  as  capable  of  raising  the  leukocyte 
count  ab)out  100  per  cent,  from  which  point  it  decreases  during  three 
weeks  to  a  normal  level.  He  states  that  sterile  ampoules  are  prepared 
by  Merck  &  Co.,  also  he  did  not  find  it  to  have  germicidal  properties; 
that  it  i  s  harmless  and  a  general  phagocytic  remedy  for  exceptional  cases. 

(b)  Vaccines: — A  vaccine  as  practically  applicable  consists  of  a 
culture  of  the  bacteria  causing  an  infection,  held  in  suspension  in  a 
liquid  vehicle,  standardized  as  to  numbers  in  a  given  quantity  (minims 
or  mils.)  and  the  bacteria  killed  by  heat. 

The  dead  bacteria  contain  toxin  which  cause  a  cell  reaction  and 
exudation  of  antibodies,  from  the  body  cells,  antagonistic  to  the 
specific  bacterium  or  bacteria  used.  Being  dead  the  bacteria  cannot 
cause  an  infection  when  injected  into  the  body.  In  brief,  the  object 
is  to  cause  such  a  reaction,  increase  the  opsonic  power  of  the  blood 
plasma  and  thus  enhance  the  power  of  the  phagocytes. 

Two  forms  of  vaccines  are  used: 

(a)  Autogenous  Vaccines. — The  infections  are  examined  micro- 
scopically the  specific  bacteria  decided  upon,  pure  cultures  or  mixed 
as  desired  made,  sterilized,  standardized  and  injected.  The  object 
is  to  use  the  cultures  of  strains  actually  causing  the  infection  as  being 
more  likely  to  produce  antibodies  specific  for  the  invading  bacteria. 
Thus  if  pus  formation  persist  and  staphylococci  he  found  as  the  pre- 
vailing infection,  these  are  isolated,  cultivated  and  used  for  the  vac- 
cine; likewise  several  may  be  used  and  mixed.     The  examination 

1  White:  Dental  Items  of  Interest,  June,  1916. 

2  Dental  Cosmos,  1918,  p.  782. 

3  Dental  Items  of  Interest,  May,  1918. 


PYORRHEA  ALVEOLARIS  AS  A  MARGINAL  GINGIVITIS     691 

may  be  made  and  the  vaccine  made  before  local  treatment  is  insti- 
tuted, though  it  would  seem  that  treatment  for  a  short  time  ^YOuld 
eHminate  the  secondary  infections  in  the  pockets. 

(h)  Stock  Vaccines. — These  are  usually  made  from  a  variety  of 
strains  of  bacteria  of  one  species  {e.  g.,  streptococci)  obtained  from  a 
large  number  of  disease  foci,  and  preferably  including  several  pyorrhea 
cases,  or  a  number  of  species  of  bacteria  are  obtained  when  infections 
may  be  mixed.  Having  selected  the  desired  bacteria,  these  are  cul- 
tivated and  a  vaccine  prepared  as  above,  standardized  as  to  numbers 
in  a  dose,  sterility  preserved  with  |  of  1  per  cent,  trikresol  or  phenol 
and  sold  in  sealed  containers,  usually  those  sealed  with  rubber 
stretched  over  the  mouth  of  the  phial  and  through  which  the  needle 
is  thrust  or  the  container  and  needle  are  combined.  If  kept  in  a  cool 
place  the  contents  are  good  for  about  a  month.  When  drawing  into 
the  syringe  the  phial  is  inverted.  Stock  vaccines  are  either  such 
cultures  suspended  in  sterile  salt  solution  without  sensitization  and 
kno"VMi  as  bacterins  or  the  bacteria  are  additionally  subjected  to  the 
influence  of  serum  drawn  from  an  animal  treated  with  large  doses 
of  the  plain  vaccine  or  bacterin  until  the  blood  of  the  animal  is  full 
of  the  specific  amboceptors.  These  amboceptors  (antibodies)  act  upon 
or  sensitize  the  bacteria  saturating  them  with  the  specific  antibodies 
"  so  that  they  do  not  absorb  antibodies  from  the  patient,  preventing 
unfavorable  local  or  general  reactions  or  the  so-called  negative  phase 
(caused  by  bacterins),  and  produce  effective,  active  immunity  in 
twenty-four  to  forty-eight  hours  which  is  reasonably  durable." 
The  preparations  so  sensitized  are  called  sensitized  vaccines  (sero- 
bacterins  by  the  MuKord  laboratories).  Muhord  laboratories  pre- 
pare what  is  called  pyorrhea  serobacterin  ]Mulford  containing  pneu- 
mococcus,  streptococcus  (various  strains).  Micrococcus  catarrhalis  25 
millions  each.  Staphylococcus  albus  and  aureus  100  millions  each, 
bacillus  influenzae  and  diphtheroid  bacilli  50  millions  each  (other 
syringes  in  multiples  of  these). 

Autogenous  vaccines  require  some  time  to  produce ;  stock  vaccines 
are  ready  for  use  and  if  prepared  by  a  reliable  laboratory  safe  for 
immediate  administration. 

Considering  the  varieties  of  causes  of  pyorrhea  suggested  as  the 
result  of  the  findings  of  bacteriologists  as  outlined  in  this  chapter. 
It  will  be  seen  that  all  that  has  been  discovered  b}'  the  use  of  vaccines 
is  that  they  lessen  symptoms  of  suppuration  and  cause  some  cures 
in  cases  not  too  hopeless  when  conjoined  v/ith  rigid  local  treatment. 

It  is  plain  that  acute  forms  of  suppuration  require  immediate 
treatment;  local,  surgical  and  antiseptic  measiu-es  and  that  stock 
vaccines  only  are  applicable. 


692  PYORRHEA  ALVEOLARIS 

In  chronic  cases  a  choice  may  be  made  and,  as  stated,  it  would  seem 
ad\dsable  to  treat  locally  and  employ  for  an  autogenous  vaccine  such 
persistent  bacteria  as  are  cultivable  or  to  use  the  stock  vaccine 
indicated  by  such  bacteria  as  are  found  on  microscopic  examination. 

If  marked  systemic  infection  be  fomid,  as  indicated  on  page  555, 
such  an  examination  should  be  made  and  the  mixed  varieties  of 
bacteria  found  cultivated  for  an  autogenous  vaccine,  or  if  urgent  an 
appropriate  stock  vaccine  used  at  once,  partly  as  a  prophylactic 
against  general  infection  as  the  result  of  local  disturbance  of  the 
infected  tissues  and  largely  to  antagonize  the  systemic  infection. 
Dming  this  treatment  the  autogenous  vaccine  may  be  prepared. 

TJie  Evidence  for  Vaccines. — McGehee^  claims  about  50  per  cent, 
of  cases  improved  markedly  through  the  use  of  the  Van  Cott  stock 
vaccines,  of  which  each  bulb  contains  in  1.0  c.c:  Streptococcus, 
50,000,000;  bacillus  coH  communis,  100,000,000;  pneumococcus, 
100,000,000;  staphylococcus  (combined  aureus,  albus,  and  citreus), 
500,000,000,  killed  and  in  sterile  solution. 

He  claimed  his  best  results  were  obtained  by  beginning  with  one- 
fourth  of  the  bulb  content,  0.25  c.c,  injecting  at  four-day  intervals, 
later  increasing  to  0.50  c.c,  and  up  to  six,  seven,  or  eight  injections 
all  told. 

Medalia^  claims  that  in  his  hands  autogenous  vaccines  com- 
bined with  the  corresponding  stock  vaccine  have  greatly  aided  in 
the  ciu-e  of  the  local  and  systemic  symptoms.  His  stock  ^'accine 
is  prepared  from  bacteria  obtained  from  various  sources  including 
several  strains  of  each  species  obtained  from  pyorrhea  cases  and 
states  that  his  cases  were  usually  treated  with  pneumococcus  and 
staphylococcus  stock  while  the  autogenous  was  also  used,  as  he 
believed  pyorrhea  due  to  a  largely  mixed  pneumococcus  and 
staphylococcus  infection  implanted  upon  a  mechanically  prepared 
area.  The  autogenous  vaccine  includes  the  predominating  bacteria 
specially  prepared  from  the  pus  of  the  patient.  His  reason  for 
the  combination  is  the  fact  that  autogenous  bacteria  are  sometimes 
incapable  of  exciting  the  formation  of  antibodies  owing  to  having 
been  affected  in  degree  by  their  host.  He  begins  with  30  to  50 
millions,  increasing  every  two  to  four  days  (or  when  reaction  has 
totally  or  partially  subsided)  by  12  to  25  millions  up  to  a  maximum 
of  400  millions  or  until  a  local  inflammatory  reaction  is  produced. 
In  marked  reactions  the  dose  is  decreased  by  12  to  25  millions. 

Head^  cites  cases  of  marked  improvement  in  cases  of  pyorrhea 

1  Dental  Cosmos,  September,  1912.  2  Ibid.,  1913,  p.  708. 

3  Jour.  Am.  Med.  Assn.,  December,  20,  1913;  Text  Book  of  Modern  Dentistry,  p. 
101, 


PYORRHEA  ALVEOLARIS  AS  A  MARGINAL  GINGIVITIS     693 

associated  with  systemic  conditions,  (a)  septic  anemia  with  red 
cells,  3,616,000,  leukocytes  4500  with  microcytes,  macrocj'^tes  and 
poikilocytes,  hemoglobin  30  per  cent,  as  cured  by  local  treatment, 
raw  eggs  three  times  a  day  and  a  vaccine  (1  diphtheroid,  1  pig- 
mented streptococcus,  1  non-hemolytic  streptococcus)  given  once 
a  week.  The  blood  result  was  hemoglobin,  50  per  cent.;  reds, 
4,000,000;  leukcocytes,  9000.  (6)  Two  cases  of  osteo-arthritis, 
unable  to  walk  or  use  muscles  as  result  of  pyorrhea,  as  satisfac- 
torily improved  by  local  treatment  (with  some  extraction)  and 
the  persistent  use  of  autogenous  vaccines  once  a  week. 

The  Evidence  Against  Vaccines. — ^A.  H.  Merritt,^  enjoying  the 
advantage  of  a  previous  large  experience  with  vaccines  in  this  connec- 
tion, claims  that  he  has  found  no  advantage  in  their  use  as  against 
strict  local  treatment,  making  the  exception  that  the  bacteria  found 
in  the  pockets  may  be  saved  or  utilized  for  the  purpose  of  antago- 
nizing with  an  autogenous  vaccine  any  accompanying  systemic 
complications.  He  bases  this  opinion  upon  his  results  with  the  local 
treatment  alone  as  compared  wdth  those  conjoined  with  use  of 
vaccines. 

Patterson-  uses  no  systemic  treatment  beyond  that  required  for 
conjoined  systemic  conditions  at  the  hands  of  the  medical  practitioner 
and  claims  good  results. 

All  observers  claim  that  exact  local  treatment  must  be  used  or 
results  are  not  obtained.  This  at  once  throws  open  the  question  as 
to  the  real  cause  of  the  cure.  Only  when  this  persistently  fails  and 
a  cure  results  from  the  use  of  systemic  treatment  (any  sort)  can 
this  be  adjudged  a  necessary  feature  of  treatment  in  cases  not  com- 
plicated by  systemic  conditions  which  is  a  different  question. 

By  this  it  is  not  meant  to  argue  against  such  treatment,  but  experi- 
ment with  a  series  of  uncomplicated  cases  should  be  tested  by  com- 
petent observers,  first  -with  local  measures  then  w^ith  vaccines,  etc., 
to  determine  the  value  of  such  as  a  sine  qua  non.  In  many  cases 
local  treatment  has  sufficed  to  cure  systemic  conditions.  It  is  noted 
in  all  cases  of  hypodermic  medication,  emetin,  vaccine,  succinamid 
of  mercury,  etc.,  that  an  induration  may  occasionally  remain  for 
some  time  about  the-site  of  injection.  Likewise  it  occasionally  occurs 
in  apical  abscess,  so  probably  it  is  due  to  a  productive  inflammation 
the  result  of  irritation.  Head^  regards  this  in  case  of  vaccine  as 
indicating  "that  the  potentialities  of  the  vaccine  injection  have  not 
been  exhausted,"  and  advises  temporarily  withholding  reinjection 
or  smaller  doses;  also  massage  for  absorption  of  the  induration. 

1  Dental  Cosmos,    1916,  p.   62.  ^  Text-book  of  Operative  Dentistry. 

3  Text-book  of  Modern  Dentistry,  p.   99. 


694  PYORRHEA  ALVEOLARIS 

Head,  modifying  Allan's  suggestion,  gives  1  ounce  lemon  juice 
three  times  a  day  (about  34  grains  citric  acid)  to  soften  the  lymph 
wall  about  a  pyorrhea  pocket  to  assist  the  vaccine  in  its  local  effects. 
Kiisel^  suggests  curettement  and  the  use  of  sodium  cinnamate  5 
grains  internally  to  assist  phagocytes  in  reaching  local  tissues.  He 
also  claims  that  vaccines  have  effect  on  the  character  and  deposition 
of  calculus. 

Object  No.  4. — The  raising  of  the  standard  of  health  is  a  medical 
problem  involving  the  entire  range  of  malnutritional  diseases.  In 
view,  however,  of  the  toxic  and  infective  effects  of  pyorrhea  and  apical 
abscess  or  granuloma,  discovery  and  removal  of  cause  should  often 
lie  with  the  dentist  though  physicians  are  alive  to  the  possibilities 
of  disease  from  teeth. 

Pyorrhea  shares  the  evil  honors  equally  with  apical  abscess. 

Causes  of  systemic  disease  removed  the  patient  may  often  recover 
without  the  assistance  of  vaccines  which  have  at  times  proved  dis- 
appointing but  may  be  resorted  to.  In  addition  the  services  of  an 
intelligent  physician  are  advisable  in  the  treatment  of  conditions 
which  may  be  the  consequences  of  dental  disease,  but  outside  of  a 
dentist's  range  of  practice  which  is  properly  confined  to  the  treatment 
herewith  indicated.  Intelligent  cooperation  will  be  found  practically 
and  ethically  satisfactory.  Certain  general  lines  of  treatment  may 
be  found  on  page  624  and  need  not  here  be  repeated. 

.    SYSTEMIC  EFFECTS  OF  PYORRHEA  ALVEOLARIS. 

It  has  been  abundantly  shown  by  Hunter  and  others  that  the  pus 
of  pyorrhea  and  other  intense  oral  sepsis  even  apart  from  apical 
infections  is  a  source  of  systemic  infection,  producing  effects  ranging 
from  gastritis  to  actual  septic  infection.  The  importance  of  this 
fact  is  not  to  be  lost  sight  of,  and  patients  are  to  be  informed  of  the 
dangers  of  constant  pus  formation  as  well  as  of  the  presence  of  other 
forms  of  sepsis  about  the  mouth  and  teeth.  In  this  connection 
salivary  calculus,  generally  unclean  teeth,  bridges  and  plates  holding 
mucous  collections,  offstanding  edges  of  crowns  collecting  food  and 
mucus,  and  the  septic  cement  under  crowns  are  of  importance  as 
well  as  gum  crevices  and  pyorrhea  pockets. 

R.  D.  Watkins,  M.D.,  has  examined  the  blood  of  pyorrhetic 
patients,  and  has  found  a  mild  condition  of  septic  blood  similar  to 
but  less  than  found  in  puerperal  fever  and  advanced  carcinoma  and 
in  other  infective  conditions.- 

1  Dental  Cosmos,  February,  1919.  =  Items  of  Interest,  1904. 


SYSTEMIC  EFFECTS  OF  PYORRHEA  ALVEOLARIS         695 

Goadby^  reports  the  cure  of  a  case  of  profound  muscular  weakness, 
mental  depression,  and  insomnia  after  unavailing  general  medical 
treatment  for  neurasthenia,  as  following  the  extraction  of  teeth 
affected  by  pyorrhea.  Craige^  believes  mental  diseases  are  due  to 
pyorrhea  and  have  been  cleared  up  by  its  cure.  VaneP  cites  a  case 
of  chronic  septicemia  with  sj^nptoms  of  pallor  and  asthenia,  and 
ecchjTBotic  patches  (see  page  28)  on  the  legs,  associated  with  pus 
formation  about  the  roots  of  teeth.  The  symptoms  disappeared  in  a 
few  weeks  after  the  oral  treatment.  Persistent  headaches  have  been 
associated  with  it. 

Hunter  and  Leith*  have  described  cases  of  subacute  and  chronic 
catarrh  of  the  stomach  and  phlegmonous  gastritis  due  to  the  ordinary 
pyogenic  cocci,  such  as  are  found  in  the  mouth,  and  which  the  gastric 
juice  of  the  stomach  of  the  particular  individual  at  least  was  not 
competent  to  kill.  Considering  the  fact  that  an  oral  subacute 
catarrhal  condition  is  established  in  pyorrhea  and  that  bacteria  are 
capable  of  multiplication  at  a  rate  of  each  twenty  or  thirty  minutes, 
the  local  transfer  of  the  infection  is  not  surprising.  Park^  believes 
many  cases  of  appendicitis  to  be  due  to  oral  infection. 

Kirk  adds  to  this  list  pernicious  anemia,  bronchopneumonia, 
malignant  endocarditis,  pyemic  lymphadenitis,  etc.,  as  possibilities 
of  secondary  infection  or  extension  by  natural  contiguous  channels. 

HartzelP  claims  that  three  deaths  from  septic  endocarditis  were 
traceable  to  violent  pyorrhea. 

Medalia  cites  cures  of  chronic  nasal,  pharyngeal,  laryngeal,  gastric, 
intestinal,  rheumatic,  arthritic,  skin  eruptive  and  diabetic  disease 
singly  or  in  combination  as  cured  or  markedly  improved  by  the  cure 
of  pyorrhea. 

Skinner  instances  a  case  of  intestinal  infection,  accompanied  by 
nervousness  and  weakness,  with  confinement  to  bed  for  three  months, 
as  rapidly  and  steadily  improving  after  the  treatment  of  a  pyorrhea 
with  profuse  suppuration.  Rheumatism  and  even  arthritis  defor- 
mans have  been  claimed  as  associated  with  pyorrhea,  the  infection 
and  toxins  being  absorbed  by  the  lymph  channels  associated  with  the 
teeth.  Rheumatic  fever  has  cleared  up  on  removal  of  pyorrhetic 
teeth.  The  bacteriology  of  this  relation  is  now  being  investigated. 
The  organism  most  often  offending  is  the  Streptococcus  viridans, 
which  may  be  isolated  from  the  blood  of  the  patients  suffering  from 

1  International  Dental  Journal,  July,  1902. 

2  Quoted  by  Wright:  See  Dental  Cosmos,  November,   1916. 
'  Dental  Cosmos,  1908,  p.  192. 

*  Transactions  Odontological  Society  of  Great  Britain,  International  Dental  Journal, 
1899. 

•Surgery  by  American  Authors.  =  Dental  Cosmos,  1908,  p.  240. 


696  PYORRHEA  ALV^OLARIS 

a  general  infection  due  to  a  local  focus  of  infection,  whether  this  be 
in  the  appendix,  tonsil,  or  a  dental  abscess  or  pyorrhea  pocket. 
Hartzell  states  that  a  small  pocket  can  keep  up  a  systemic  infection 
once  it  is  established.  It  grows  upon  blood  agar  with  a  green  color 
in  its  colonies.  Park  and  Williams  claim  a  variety  of  strains.  If 
the  same  bacteria  can  be  isolated  from  the  blood  and  the  focus  and 
the  condition  clear  up  upon  removal  of  the  latter,  the  relation  is 
absolute.  In  brief  it  seems  to  share  equally  with  apical  granuloma 
the  evil  honor  of  causing  disease.  It  requires  much  courage  to  advise 
the  loss  of  teeth  and  lines  of  dental  work  in  cases  of  minor  systemic 
symptoms,  when  the  loss  involves  a  large  line  of  subsequent  work, 
but  in  view  of  the  apparent  demonstration,  that  even  slight  pyor- 
rhea pockets  may  maintain  a  systemic  infection,  the  possible  con- 
nection should  be  pointed  out  to  the  patient  and  at  least  the  worst 
teeth  removed  and  others  vigorously  treated.  Physician  and  dentist 
should  advise  together  to  endeavor  to  eliminate  systemic  compli- 
cations. Unfortunately  a  physician's  statement,  even  when  based 
only  on  general  principles  and  w^ithout  definite  knowledge  of  a  case, 
is  often  accepted  as  final  when  the  most  potent  arguments  of  a  dentist 
are  unconvincing.  The  neglect  of  conditions  tending  to  pyorrhea 
and  of  actual  pyorrhetic  conditions  is  one  of  the  commonest  over- 
sights of  dentists  due  in  part  to  the  lack  of  understanding  on  their 
part  and  of  appreciation  of  their  mouths  by  patients.  (See  page  555 
and  Prophylaxis.) 


PYORRHEA  ALVEOLARIS  NOT  DEPENDENT  UPON  CALCULUS 

FORMATION. 

A  form  of  pyorrhea  occurs  in  which  calculus  does  not  seem  to  be 
the  exciting  or  contributory  cause.  It  seems  rather  to  be  due  to 
infection  localized  in  soft  bacterial  collections  in  localities  protected 
from  ordinary  friction. 

Sometimes  no  perceptible  calculus  can  be  found  upon  the  roots, 
but  a  soft  gummy  collection  may  be  noted.  The  forms  of  the  necks 
of  the  teeth  readily  permit  bacterial  collections  and  the  infection 
causes  a  bright  red  marginal  gingivitis,  sometimes  localized  to  a  single 
portion  of  the  gum  margin.  A  pocket  forms  and  the  infection  becomes 
deep.  The  gum  tissue  is  sometimes  destroyed  between  two  teeth. 
There  is  often  e^'idence  of  infection  of  other  gum  margins  with  the 
bright  red  color.  In  another  form  the  gum  margins  are  separated 
from  the  teeth.  Pockets  are  formed  which  coUect  food.  There  is 
not  much  pus  apparent,  but  there  is  a  pigsty  odor  of  putrefaction. 


PYORRHEA  ALVEOLARIS  697 

The  marginal  bone  is  lost.  In  another  form  a  deep  pocket  forms  and 
necrotic  bone  may  be  fomid. 

The  advance  of  the  disease  is  sometimes  rapid  and  sometimes  not. 
Sometimes  a  lateral  abscess  is  associated  with  it.  The  diagnosis  is 
that  of  pyorrhea  alveolaris  of  aggravated  type,  and  probably  special 
infection,  and  its  progress,  diagnosis,  symptoms,  and  treatment  are 
practically  the  same  as  in  the  first  class. 

The  advance  of  the  case  may  be  very  slow  and  limited  to  the 
teeth  originally  involved.    The  following  is  an  example : 

INIiss  H.,  aged  twenty-five  years,  presented  with  well-established 
pockets,  extending  one-half  inch  toward  the  apex,  upon  the  mesial 
aspect  of  the  root  of  the  right  upper  central  incisor  and  distal  and 
distobuccal  aspect  of  the  right  upper  lateral  incisor.  There  was  a 
history  of  traumatism  due  to  violent  and  persistent  wedging  with 

Fig.  677 


Pyorrhea  alveolaris  without  calculus.  Pockets  as  shown.  Teeth  were  one-sixteenth 
inch  longer,  but  have  been  shortened.  Practically  no  calculus  and  but  slight  flow  of 
thick,  creamy  pus.    Gum  prominent  over  aifected  teeth.     Condition  in  1904. 

rubber  at  about  the  age  of  sixteen.  The  case  was  then  of  several 
years'  standing,  and  the  two  teeth  elongated  about  one-eighth  inch 
beyond  their  fellows  (Fig.  677).  There  was  no  subgingival  calculus. 
The  pockets  were  treated  with  some  benefit,  and  the  teeth  shortened 
for  the  cosmetic  effect,  but  the  patient  left  the  city  suddenly  before 
recovery,  and  was  not  seen  again  for  three  years,  i^t  this  second 
visit  it  was  found  that  the  pockets  were  nearly  the  same  as  at  first, 
and  no  other  teeth  had  become  involved.  Nor  had  the  teeth  further 
elongated. 

During  the  four  succeeding  years,  elongation  and  grinding  reduced 
nearly  all  the  brown  of  the  lateral,  which  had  one-quarter  inch  of 
its  root  cervix  exposed.  Coincidently  with  the  exfoliation  the  pockets 
disappeared  as  though  by  a  drawing  up  of  the  bottom.  The  two 
teeth  were  finally  lost. 


CHAPTER  XXII. 
PERICEMENTAL  ABSCESS. 

In  comparatively  rare  cases  there  begins  in  the  lateral  aspect  of  a 
pericementum  a  swelling  which  finally  discharges  its  contents  either 
at  the  gum  margin  or  directly  through  the  gum  tissue. 

The  pulp  of  the  tooth  may  be  perfectly  vital  and  the  attachment  at 
the  gum  margin  at  first  at  least  practically  unbroken.  A  deposit  of 
calculus  may  or  may  not  be  formed  in  the  area,  and  the  discharge  may 
consist  of  a  glairy  fluid  or  of  purulent  matter.  Cases  of  this  disease 
have  been  noted  and  described  by  Darby  (1874),  W.  E.  Walker 
(1895),  Talboti  (1896),  D.  D.  Smith  (1897),  and  Kirk  (1898).  Black 
claims  that  he  has  never  found  such  a  condition  without  local  injury. 

Forms  of  Pericemental  Abscess. — There  are  four  forms  of  perice- 
mental abscess  as  described  and  seen : 

1.  An  ordinary  pyorrhea  begins  at  the  gum  margin  and  extends 
into  the  alveolus  at  the  expense  of  the  pericementum.  The  bacteria 
find  their  way  to  the  bottom  of  the  pocket  or  into  the  tissue  at  its 
side.  They  develop  in  the  said  location  and  the  pus  burrows  into 
the  lateral  gingival  tissue,  causes  swelling  and  pointing,  and  dis- 
charges at  the  lateral  gingival  aspect  or  analogous  situation.  (See 
page  662.)  This  is  not  always  opposite  the  gum  orifice  of  the  pocket. 
(See  Figs.  638  and  639.)  In  one  case  a  fistula  was  found  at  the  buccal 
aspect  of  the  gum  opposite  a  point  midway  between  the  buccal  roots 
of  an  upper  molar  at  the  middle  third  of  the  roots.  The  pulp  was 
exposed  and  vital,  having  been  drilled  to  on  the  supposition  of  its 
death.  A  giun  pocket  was  found  at  the  distolingual  aspect  of  the 
lingual  root  and  the  pus  had  burrowed  into  the  bifurcation  between 
the  lingual  and  distobuccal  root,  and  discharged  as  stated,  remain- 
ing as  a  chronic  abscess.  There  is  a  simple  acute  condition  of  this 
kind  of  origin  seen  occasionally.  A  swelling  of  the  gum  margin 
occurs  and  pointing  occurs,  lancing  usually  demonstrates  pus  present 
and  effects  a  cure.  The  infection  has  entered  the  gingival  space, 
travelled  into  the  tissue  and  developed  what  may  be  term^ed  a  true 
marginal  gingival  abscess. 

'  International  Dental  Journal,  1896. 
(  698  ) 


PERICEMENTAL  ABSCESS  699 

2.  There  is  a  pyorrhetic  condition  at  the  gum  margin,  though  no 
particular  pus  flow  is  noted.  The  gimis  are  often  flabby  and  the  teeth 
usually  isolated  and  overstrained;  later  an  abscess  develops  on  the 
lateral  aspect  at  a  point  a  little  higher  up  toward  the  apex,  usually 
at  the  gingival  third.  There  may  be  no  detectable  connection  between 
the  two,  but  probably  a  deeper -infection  has  occurred,  the  avenue 
being  along  the  connective-tissue  spaces,  the  bloodvessels  or  the  glands 
of  Black.  HartzeU  and  Henrici  claim  to  have  foimd  Streptococci 
^'iridans  deep  in  pericemental  tissue  (see  page  654) .  In  one  case  of  this 
sort  the  fistula  was  formed  over  the  highest  point  of  the  middle 
third  of  the  root  of  a  cuspid  retained  for  plate  work.  The  giun 
margin  was  flabby,  but  not  markedly  pyorrhetic.  There  was  firm 
tissue  at  the  bottom  of  the  space  on  all  sides.  The  pulp  was  vital. 
Examination  showed  a  small  calculus  on  the  root  surface  below  the 
fistula.  The  abscess  tract  was  limited.  Sometimes  it  is  of  greater 
extent.     Fig.  640  will  illustrate  how  this  occurs. 

3.  An  acute  swelling  occurs  over  a  root,  the  gimi  margin  is  un- 
broken, a  discharge  of  glairy  or  pm-ulent  material  occurs,  and  a 
calculus  or  none  may  be  found.  In  this  connection  Fig.  233  shows 
that  a  calculus  may  exist  as  a  primary  cause  of  the  pericemental 
abscess.  As  calculi  of  gouty  (sodium  bi-urate)  or  other  origin  occui 
in  other  parts  of  the  body  and  in  the  pulp,  there  is  no  vaHd  reason 
why  one  should  not  occur  in  the  pericementum  or  upon  the  root 
under  it  if  some  sluggish  condition  of  the  circulation  renders  the 
tissues  into  a  degenerative  state  favoring  it.  (See  page  62.)  The 
pericementlun  contains  white  fibrous  tissue  which  is  particularly 
prone  to  such  deposits. 

^Miether  such  a  deposit  occurred  primarily  in  the  case  of  the  cuspid 
described  under  Class  2  and  infection  followed,  or  whether  the  infec- 
tion and  pus  came  first  and  the  calculus  followed  is  not  quite  clear. 
In  two  distinct  cases,  v^-ith  healthy  gum  margins,  the  editor  has 
seen  an  acute  circumscribed  swelling  which  was  not  yet  open  as  a 
fistula  and  which  was  perforated  by  an  explorer,  disclosing  a  loss 
of  alveolar  bone  and  a  smaU  cavity  fifled  with  clear  hquid  in  the 
tissues.  The  explorer  reached  the  root  without  obstruction,  and 
no  calculus  was  present.  After  discharge  and  curettement  the 
cavities  healed.  These  two  swellings  looked  Hke  bhsters  or  simple 
cystic  swellings  near  the  gmn  margin.  If  they  had  discharged  at 
the  gum  margin  they  might  have  produced  a  gum  pocket  simulating 
pyorrhea.  The  theory  of  a  granulomatous  formation  has  been  sug- 
gested. As  this  may  lead  to  cyst  formation  in  apical  granuloma  it 
is  a  reasonable  hypothesis  though  the  two  cases  above  did  not  con- 
tain proliferated  tissue,  some  of  the  cases,  however,  appear  as  though 
such  a  tissue  had  been  previously  formed. 


700 


PERICEMENTAL  ABSCESS 


In  another  case  a  right  upper  bicuspid  was  in  non-occhision,  pyor- 
rhea had  been  apparently  cured  upon  the  distal  and  the  gum  was 
receded  for  a  quarter  inch.  A  year  or  two  later  acute  pain  super- 
vened; there  was  no  evidence  of  swelling,  but  a  soft  spot  was  found  on 
the  gum  surface  over  the  absorbed  alveolar  process  about  one-third 
inch  from  the  tooth.  It  was  opened  and  a  sinus  with  no  evident  pus 
thus  established  to  a  point  perhaps  a  quarter  inch  above  the  resorbed 
gum  margin.     It  has  been  healed  for  a  year  at  this  writing. 

4.  In  some  cases  of  apical  abscess  the  infection  may  travel  along 
the  pericementum  and  develop  a  secondary  abscess  at  some  point 
in  the  pericementum  (as,  for  example,  the  bifurcation),  as  a  perice- 
mental abscess.  This  form  corresponds  to  the  cases  of  Class  2,  but 
is  apt  to  be  more  acute.  It  is  also  quite  rare.  The  pulp  is,  of  course, 
dead,  at  least  partially  in  such  a  case. 

The  subject  of  pericemental  abscess  is  in  some  confusion  because 
writers  have  described   all  these  varying  phases  as  pericemental 

abscess,  which  indeed  they  are. 
Fig.  678  yet    they    require   differentiation 

into: 

1.  Cases  occurring  as  a  sequel 
to  a  distinct  pyorrhea  alveolaris, 
Class  1. 

2.  Casesa  ssociated  with  margi- 
nal pyorrhea  cases  but  distant  to 
them,  in  all  probability  having  a 
source  of  infection  in  the  pyorrhea 
pockets.  Class  2. 

3.  Cases  beginning  on  their  own 
account;  the  relation  of  the  cal- 
culus if  present  as  a  cause  or  re- 
sult being  in  doubt,  Class  3  (Figs. 
679  and  680). 

4.  Cases  beginning  in  an  apical 
abscess  infection  or  similarly  on  a 
perforation,  travelling  via  the  peri- 
cementum to  another  portion  of 
the  pericementum,  Class  4. 

Garrod  found  crystals  of  urates  in  the  serum  of  blisters  in  gouty 
patients.  In  gouty  patients  they  are  found  in  joints,  and  they  con- 
stitute the  common  tophus.  (See  page  62.)  "Urates  of  sodium  are 
also  discharged  through  the  skin  in  gouty  abscesses,  either  in  liquid 
or  solid  form,  and  with  or  without  pus."    (Musser.)    Musser^  states 


Tophi  of  gout.     (Ziegler.) 


'  Medical  Diagnosis. 


PERICEMENTAL  ABSCESS 


701 


that  a  number  of  these  abscesses  may  discharge  without  impair- 
ment of  the  general  health  or  even  with  benefit  to  the  system. 

Calculi  scraped  from  the  roots  in  pericemental  abscesses  exhibit 
in  a  varying  degree  a  response  to  the  murexid  test,  the  test  for 
urates.  (Peirce.)  The  reaction  may  be  very  faint  in  some  cases, 
being  overshadowed  by  the  calcium  phosphate  which  makes  up  the 
bulk  of  these  masses;  in  others  it  is  pronounced — i.  e.,  urates  made 
up  a  portion  of  the  deposits. 

Black^  by  test  found  urates  in  nearly  all  concretions,  salivary  and 
serumal,  about  the  teeth.  While  he  claimed  that  this  proved  that 
urates  have  no  causal  relation  to  pyorrhea,  the  findings  seem  rather 
to  point  to  frequent  presence  of  urates  in  the  salivary  and  serumal 
excretions,  which  may  really  be  a  cause  of  irritation  even  when  no 
obvious  symptoms  of  gout  are  present. 


Fig.  679 


Fig.  680 


A  and  C,  vital  pericementum,    B,  gouty  cal- 
culus;  D,  a  subgingival  calculus. 


A,  calculus  in  area  Of  necrosis 
B,  and  C,  vital  pericementum. 


Miller's  demonstration  of  a  calculus  upon  an  unerupted  tooth  is 
to  be  recalled.  It  seems  fairly  reasonable,  therefore,  to  suppose 
that  in  rare  cases  such  a  calculus  may  be  the  result  of  either  gout 
or  a  local  degeneration  and  act  as  an  exciting  cause. 

Morbid  Anatomy. — Aside  from  the  state  of  the  teeth  which  show 
evidences  of  a  tendency  to  secondary  dentin  and  nodule  formation, 
it  has  been  noted  that  the  abscess  is  intrapericemental,  not  sub- 
pericemental.  Figs.  681  and  682  show  the  inflammatory  swelling  of 
the  pericementum;  the  central  abscess  cavity,  and  the  loss  by  resorp- 
tion of  the  alveolar  process  may  easily  be  calculated.  The  original 
chronic  nature  of  the  local  irritation  in  this  case  is  evidenced  by 
the  presence  of  hypercementosis.  The  case  in  Fig,  681  suggests  a 
granuloma. 


J  Dental  Review,  1894, 


702 


PERICEMENTAL  ABSCESS 


Symptoms. — These  have  been  largely  foreshadowed  in  the  dis- 
cussion of  the  pathology.  Upon  some  tooth,  often  a  vital  tooth,  there 
appears  an  uneasiness,  at  first  not  very  painful,  followed  later  by  an 


Fig. 


Two  views  of  an  intrapericemental  abscess.    Pulp  vital.    (Kirk.) 
FiQ.  682 


Transverse  section  through  buccal  roots  and  pericemental  abscess  shown  in  Fig. 
681,  showing  intrapericemental  abscess  cavity  with  fistulous  outlet  and  nearby  areas 
of  nodular  hypercementosis.     (Kirk.) 


PERICEMENTAL  ABSCESS  703 

inflammatory  swelling  which  may  produce  acute  pain  and  then  dis- 
charge a  glairy  fluid  or  purulent  matter.  There  is  an  absence  of 
the  marked  phlegmonous  inflammatory  involvement  of  contiguous 
tissues  common  in  cases  of  acute  apical  abscess.  The  fistula  may 
persist  after  the  discharge  and  the  case  may  first  be  seen  in  this  con- 
dition. If  it  discharges  at  the  gum  margin  it  estabhshes  an  ordinary 
pyorrhea. 

Fig.  683 


Pericemental  abscess.    (Talbot.)     (Photograph  by  Latham.) 

D.  D.  Smith  calls  attention  to  the  absence  of  marked  pain  upon 
tapping  and  the  production  of  a  feeling  of  apprehension  upon  the 
part  of  the  patient  during  the  stages  preceding  the  formation  of  the 
fistula.  In  other  cases  the  shifting  of  the  tooth  from  its  position  is 
the  first  noticeable  symptom,  followed  later  by  the  pain,  and  later 
still  by  the  discovery  of  a  pocket  alongside  the  tooth. 

Diagnosis. — In  making  the  diagnosis  the  symptoms  described  are 
to  be  borne  in  mind,  but  the  disease  may  be  confounded  with  several 
diseases  having  somewhat  similar  symptoms.  An  acute  apical 
abscess  due  to  gangrenous  pulp  may  be  differentiated  by  obtaining 
evidences  of  pulp  death,  previous  root-canal  treatment,  etc.  There 
is  also  much  greater  pain  upon  percussion  than  in  pericemental 


704 


PERICEMENTAL  ABSCESS 


Fig.  684 


abscess.    If  slowly  and  painlessly  formed  it  may  be  still  more  con- 
fusing, but  the  pulp  is  dead. 

If  the  apical  abscess  be  in  the  third  stage  it  may  be  differentiated, 
if  any  doubt  exist,  by  incision  and  subsequent  exploration. 

An  acute  lateral  abscess  due  to  a  root  perforation  is  more  difficult 
of  differential  diagnosis,  but  after  incision  evidences  of  perforation 
may  be  sought  externally,  or  the  root  canal  may  be  opened.  In 
these  acute  conditions  the  a:-ray  may  render  valuable  aid.  Trans- 
illumination of  the  alveolar  process  with  a  powerful  electric  mouth  or 
antral  lamp  may  demonstrate  a  more  deeply  colored  area.  The  pulp 
being  found  alive  by  any  reliable  test  is  evidence  that  the  case  is  not 
apical  abscess  and  probably  pericemental  abscess.  In  a  few  cases  of 
partial  gangrene  of  the  pulp  the  pulp  may  test  as  vital,  yet  really  the 
symptoms  be  due  to  apical  abscess. 

Treatment. — If  the  pericemental  abscess 
discharge  by  way  of  the  gum  margin,  infec- 
tion from  the  oral  cavity  occurs  and  the 
pocket  originally  formed  becomes  deeper. 
The  case  simulates  then  a  pyorrhea  alveolaris 
beginning  at  the  gum  margin.  The  treatment 
is  then  conducted  accordingly.  If  the  swell- 
ing occur  upon  the  gum,  at  a  point  more  of 
less  midway  upon  the  root,  or  if  transillumi- 
nation demonstrates  a  deep  inflamed  spot  and 
the  pain  warrant,  it  should  be  opened  under 
antiseptic  precautions.  A  semicircular  flap  may 
be  raised,  or  a  simple  incision  made  preferably  mider  local  anesthesia 
in  some  form.  The  diseased  area  should  be  explored  for  calculus  and, 
whether  found  or  not,  the  necrotic  tissue  should  be  curetted  away. 
Next,  the  pocket  should  be  syringed  out  with  an  antiseptic  and  filled 
with  balsam  .of  Peru  or  a  clot  induced.  The  flap  is  next  laid  into 
place.  The  mouth  should  be  kept  in  an  aseptic  condition  during  the 
healing  of  the  parts.  It  is  well  to  have  the  patient  keep  the  sinus 
open  with  a  needle  to  ensure  heahng  from  the  bottom  rather  than 
ballooning  by  pus,  which  may  cause  recm-rences.  The  systemic 
considerations  are  the  same  as  those  described  for  pyorrhoea. 

The  cases  are  sometimes  annoyingly  recurrent  and  in  case  of 
isolated  teeth  the  overstrain  may  render  them  incm-able.  Those 
cases  in  which  the  pocket  is  associated  with  a  groove  between 
buccal  roots  of  upper  molars  with  which  a  crevice  between  roots 
exists  are  practically  hopeless,  as  there  is  persistent  inaccessible 
infection. 


A,  calculus. 


CHAPTER  XXIII. 
REFLEX  NEUROSES. 

Reflex  neuroses  consist  of  (1)  pain  produced  in  parts  distant 
to  the  point  at  which  irritation  is  produced,  while  pain  may  or 
may  not  be  absent  at  that  point  (sensory  reflexes),  or  (2)  they  may 
consist  of  muscular  excitation  in  parts  distant  to  the  cause  (motor 
reflexes),  or  (3)  they  may  consist  of  nutritive  disturbances  in  the 
distant  part,  probably  a  form  of  motor  reflex  in  which  the  trophic 
nerves  or  the  vasomotor  nerves  are  reflexly  irritated  so  as  to 
produce  trophic  disturbances. 

The  source  of  irritation  may  be  in  the  dentinal  fibril,  in  the  pulp, 
or  in  the  pericementum,  producing  sensory  or  motor  or  trophic 
reflexes  in  other  parts  or  the  source  of  irritation  may  be  in  some 
other  location  than  about  the  teeth  and  produce  phenomena  about 
the  face  or  teeth. 

Whether  of  dental  origin  or  not  a  sensory  reflex  is  called  neu- 
ralgia, though  the  cause  of  a  neuralgia  may  possibly  be  a  direct 
irritation  of  a  nerve  trunk  or  terminal. 

While  all  reflex  dental  disturbances  are,  as  a  rule,  located  in  some 
part  of  the  great  nerve  branch  supplying  the  source  of  irritation, 
the  irritation  may  be  reflected  to  distant  parts;  first,  of  the  same 
cranial  nerve,  and  secondly,  to  other  nerves.  That  is,  pain  having 
its  origin  in  one  of  the  upper  teeth  is  most  likely  to  be  referred  to 
a  point  or  points  in  the  distribution  of  the  superior  maxillary  divi- 
sion of  the  fifth  nerve.  Disturbances  in  or  about  the  lower  teeth 
are  usually  referred  to  the  distribution  of  the  inferior  maxillary 
division.  In  affections  of  either  upper  or  lower  teeth  the  pain  may 
be  referred  to  the  ophthalmic  division.  In  all  of  these  cases,  but 
most  notably  in  connection  with  disturbances  of  the  upper  teeth, 
the  usual  symptom  of  trifacial  neuralgia — tenderness  of  the  supra- 
orbital and  infraorbital  nerves  at  their  points  of  emergence  upon 
the  face,  the  supraorbital  and  infraorbital  foramina — is  commonly 
present.  A  reflex  may  be  multiple,  that  is,  to  several  points  at  once 
e.  g.,  in  one  case  the  sensations  were  felt  in  the  ear,  temple,  mastoid 
region  and  about  a  molar  tooth.  The  cause  was  apparently  a  small, 
"headless  boil"  in  the  external  auditory  meatus. 

The  writer  believes  that  to  some  extent  all  the  varieties  as  above 
45  (705) 


706  REFLEX  NEUROSES 

defined  are  to  an  extent  commingled  inasmuch  as  a  persistent  sensory- 
reflex  to  some  locality  results  in  tenderness  of  the  spot,  showing  a 
hyperemia  due  to  a  vasomotor  reflex  via  the  sympathetic  system 
and  therefore  a  trophic  reflex. 

Cases  are  extremely  rare  where  the  reflex  pain  is  referred  to  the 
opposite  side;  so  unusual  is  this  occurrence  that  its  mention 
warrants  suspicion  that  other  sources  of  irritation  exist  upon  the 
side  referred  to. 

The  extent  of  acuteness  of  reflex  pain  bears  no  direct  relation  to 
the  apparent  extent  of  the  source  of  irritation. 

As  might  be  surmised  from  the  function  of  the  dental  pulp,  painful 
reflex  dental  disorders  are  more  common  in  connection  with  diseases 
of  the  pulp  than  with  those  of  the  pericementum. 

In  diseases  of  the  eye  the  reflexes  are  usuaUy  referred  to  branches 
of  the  ophthalmic  division. 

REFLEX  NEURALGIA  FROM  EXPOSED  DENTIN. 

The  exposure  of  the  dentin  to  external  sources  of  irritation  is 
followed  by  reactions  governed,  first,  by  the  degree  of  sensitivity 
inherent  in  the  protoplasm  of  the  tissue;  and  secondly,  by  the  degree 
of  hypersensitivity  induced  in  it.  Reflex  disturbance  due  to  these 
irritations  is  more  common  in  the  class  of  persons  called  "neural- 
gics,"  i.  e.,  in  those  whose  nervous  irritability  is  exalted,  a  condi- 
tion which  may  remain  even  in  nervous  exhaustion.  Like  direct 
pulp  pains,  unless  actual  pressure  be  exerted  upon  the  affected 
tissue,  there  is  no  localized  pain.  In  the  absence  of  deliberate  irri- 
tation, the  pain  may  be  referred  to  any  portion  of  the  peripheral 
distribution  of  the  fifth  nerve  upon  the  face,  but  if  an  acid  liquid, 
such  as  lemon  juice  or  vinegar,  or  sugars  be  taken  into  the  mouth, 
pain  is  excited,  which  is  referred  indefinitely  to  the  teeth  of  one  side, 
frequently  of  one  jaw.  Reflex  pains  due  to  this  cause  often  appear 
when  there  is  but  little  loss  of  dentin. 

When  carious  cavities  have  proceeded  to  any  depth  evidences  of 
direct  pulp  disturbance  are  obtained  through  the  increased  response 
to  thermal  changes. 

Reflex  pains  from  exposed  dentin  appear  most  commonly  in  con- 
nection with  exposures  at  the  neck  of  the  tooth  and  upon  abraded 
areas.  Obstinate  and  persistent  neuralgia,  positively  referred  to 
another  nerve  branch,  may  apparently  owe  its  origin  to  so  slight  a 
cause  as  exposure  at  the  neck  of  a  tooth  of  a  line  of  dentin  (Fig.  686) . 
The  proof  of  the  connection  between  the  two  is  made  clear  by  a 
disappearance  of  the  neuralgia  after  the  exposed  dentin  has  been 


Fia.  685. Plan  of  the  fifth  cranial  nerve,  showing  the  relationships  of  the  dental 

nerves.    (After  Flowers.) 


708  REFLEX  NEUROSES 

subjected  to  the  action  of  powerful  caustics  (especially  silver  nitrate), 
destroying  the  dentinal  filaments  to  some  depth.  The  connection 
between  the  two  may  be  revealed  only  by  accident;  the  contact  of 
a  toothpick,  a  dental  instrument,  or  the  finger-nail  may  induce  a 

paroxysm  of  pain.    In  one  case, 

^i°-  686  after   removal   of    calculus,    the 

I  necks  of  the  lower  incisors  be- 

^^^^^^  1^"^^^::;:^^         came  a  cause  of  severe  neuralgia, 

^^\     Y     4      rj_-      compelling  the  use  of  silver  ni- 

V^   '  y  \\!i.%v%  %\  While  in  some  cases  the  dental 

V-V  ^'^..j       origin  of  reflex  pain  may  be  made 

Sites  of  dentin  exposure  frequently  asso-         ,  i      •     i        •  p  •    p   i 

dated  with  reflex  pains.  clear  by  the  mduction  ot  a  pamtul 

response  in  the  area  of  reflection, 
by  irritating  a  tooth  pulp,  this  reaction  is  not  constant.  The  causal 
relation  is  only  certain  when  the  cure  of  localized  dental  disease 
is  followed  by  a  disappearance  of  the  neuralgia  without  further 
treatment.     This  proof  should  be  exacted  in  all  cases. 

REFLEX  NEURALGIAS  FROM  PULP  DISEASES. 

The  disturbances  require  classification  according  to  the  distance 
between  their  source  and  their  manifestations. 

In  the  Fifth  Pair  of  Nerves. — In  neuralgic  patients  any  variety 
of  pulp  disease  may  cause  comparatively  distant  pains.  But,  as 
Black  has  pointed  out,^  the  general  rule  is,  that  the  more  chronic  and 
profound  degenerative  diseases  of  the  pulp  are  much  more  liable  to 
give  rise  to  distant  reflex  pains  than  are  acute  pulp  diseases. 

The  pains  of  acute  hyperemia  and  of  acute  inflammation  of  the 
pulp  are  usually  referred  to  the  region  of  the  tooth  affected,  or  to  a 
corresponding  nerve  trunk.  In  conditions  of  nodular  calcifications, 
chronic  inflammation,  and  pulp  degenerations,  the  source  of  the  reflex 
pains  is  all  the  more  obscure  from  the  fact  that  in  these  chronic 
degenerations  direct  dental  symptoms  may  be  entirely  absent,  and 
are  only  elicited  upon  the  most  searching  examination  and  exhaustive 
tests.  In  some  cases  of  pulpitis  even  removal  of  the  pulp  by  cocain 
has  been  followed  by  a  neuralgia  due  to  irritation  of  the  nerve  trunk 
in  the  pulp  stump  at  the  apex,  so  proved  by  cure  through  strong 
sedatives  applied  via  the  canal.  In  one  case  the  neuritis  lasted 
several  days. 

There  is  no  constancy  in  the  location  of  the  pain  due  to  any  of 

1  American  System  of  Dentistry,  vol.   i. 


REFLEX  NEURALGIA  FROM  EXPOSED  DENTIN 


709 


Fig.  687 


Spots   of   tenderness   in   reflex 
neuralgias  of  dental  origin. 


these  causes;  but  pain  in  or  about  the  eye,  supraorbital  foramen, 
infraorbital  foramen,  side  of  the  nose,  the  temporal  and  anterior 
auricular  region,  in  the  ear,  down  the  side  of  the  neck,  in  the  mastoid 
region,  even  to  the  shoulder,  the  arm  and  about  the  heart.  The  pains 
may  be  acute  and  lancinating  or  merely  of  a  mild  nature  or  possibly 
the  condition  of  localized  "tenderness"  may  develop.  Many  of  these 
cases  receive  attention  from  the  general 
practitioner,  and  the  painful  attacks  re- 
curring at  irregular  intervals  are  relieved 
by  analgesic  remedies — phenacetin,  acet- 
anilid,  exalgin,  etc. — and  no  attention 
paid  to  a  probable  dental  source  of  the 
disorder.  It  should  be  a  routine  practice 
to  examine  the  teeth  in  cases  presenting 
pains  of  the  type  and  in  the  situations 
described.  Acute  diseases  of  the  pulp, 
including  suppuration,  notably  abscess 
of  the  pulp,  usually  have  attention  di- 
rected to  the  teeth  through  pain  induced 
by  thermal  changes,  so  that  their  diag- 
nosis is  quickly  made.    Not  so,  however, 

with  the  chronic  degenerative  changes,  except  possibly  of  pulp 
nodules;  for  if  the  pulp  is  in  the  late  stages  of  degeneration,  it  may 
require  repeated  applications  of  cold  and  heat  to  elicit  a  response 
from  teeth  which  do  not  respond  by  tenderness  upon  percussion. 

Faihng  to  obtain  evidence  of  pulp  disorders,  examination  should 
be  made  for  exposed  and  hypersensitive  dentin.  Then,  examination 
of  the  pericemental  reaction  of  each  tooth  should  be  made,  and  for 
any  evidences  about  the  teeth  pointing  to  pericemental  disturbance. 
(See  page  483.) 

Lauder  Brunton^  records  that,  in  his  own  case,  temporal  neuralgia 
accompanied  by  tender  eyeball  was  found  due  to  exposed  dentin 
upon  the  posterior  cervical  surface  of  a  lower  third  molar  (see  Fig. 
686) .  The  same  writer^  announces  that  "  so  frequently  are  headaches 
dependent  upon  decayed  teeth,  that  in  all  cases  of  headache  the 
first  thing  I  do  is  to  carefully  examine  the  teeth;"  as  should  every- 
one else.  Upson  cites  by  radiograph  a  case  of  severe  headaches  of 
years  standing,  cured  by  extraction  of  an  impacted  cuspid.^  Brunton 
explains  the  painful  reaction  upon  the  accepted  hypothesis  of  the 
pathology  of  megrim,  that  it  is  due  to  spasmodic  contraction  of  the 

1  St.  Bartholomew's  Hosp.  Rep.,  vol.  xix.     Reprinted  in  his  Disorders  of  Digestion. 

2  Ibid. 

3  Raper,  Items  of  Interest,  August,  1912,  p.  575. 


710  REFLEX  NEUROSES 

peripheral  end  of  an  artery,  with  dilatation  of  the  proximal  portion. 
"Irritation  in  the  tooth  is  reflected  to  the  cervical  sympathetic 
ganglia  and  causes  spasmodic  contraction  of  the  arteries  through 
irregular  stimulation  of  the  vasomotor  nerves." 

An  abnormal  tooth  located  in  the  anterior  floor  of  the  nasal  cavity 
was  the  cause  of  headache  for  years,  so  proved  by  cessation  of  head- 
ache after  its  surgical  removal.  When  sepsis  is  present  one  must 
differentiate  between  reflex  neurosis  as  above  and  a  possible  trans- 
ference of  infection  from  foci  of  infection,  as  various  cases  of  iritis, 
headache,  etc.,  have  been  due  to  apical  granuloma,  pyorrhea,  etc.  (see 
pages  561  and  694)  and  may  possibly  be  due  to  septic  living  pulp 
The  cerebral,  intestinal  and  other  symptoms  arising  in  pathological 
first  dentition  are  mainly  referable  to  pulp  disturbance  (see  page 
70)  and  reflexes  arising  therefrom. 


REFLEX  PAINS  FROM  DISEASES  OF  THE  PERICEMENTUM. 

As  a  general  rule,  pericemental  pains  are  located  at  the  affected 
tooth;  but  in  some  of  the  disorders  the  teeth  may  not  be  tender  upon 
percussion,  and  yet  excite  reflex  pains  in  other  parts,  the  proof  of 
the  connection  being  determined  by  a  disappearance  of  the  pain 
upon  extraction  of  the  tooth.  The  roots  in  such  cases  usuaUy  present 
either  a  hypercementosis  or  show  that  resorption  of  a  portion — it 
may  be  a  major  portion — of  the  root  has  occurred. 

In  cases  of  hypercementosis  it  is  assumed  that  the  source  of  the 
irritation  is  pressure  upon  the  nerves  of  the  pericementum  by  the 
hypertrophic  growth.  Very  widespread  disorders  may  arise  from 
this  source. 

Flagg^  records  many  varieties  of  trifacial  neuralgia;  pains  in  remote 
parts  of  the  body;  grave  functional  disorders  of  the  eye  and  ear; 
and  motor  disturbances — chorea,  epilepsy,  and  paralysis — having  a 
direct  demonstrable  connection  with  hypercementosis.  Insanity  has 
also  been  produced. 

He  mentions  violent  attacks  of  trifacial  neuralgia  as  the  most 
common  reflex  disturbance  from  this  source ;  and  next,  long-continued 
pains  in  the  ear  or  eye  of  the  affected  side.  The  existence  of  acute 
disease  of  these  organs  is  usually  diagnosed  by  the  general  practi- 
tioner. He  states  that  aural  and  ocular  disturbances,  both  functional 
and  painful,  are  of  gradually  increasing  severity. 

In  examining  for  a  dental  source  of  such  pains,  exposed  dentin, 

1  Dental  Cosmos,  1878. 


REFLEX  PAINS  FROM  DISEASES  OF  THE  PERICEMENTUM     711 

pulp  diseases,  and  inflammatory  affections  of  the  pericementum 
should  be  first  excluded.  In  examinations  by  percussion  a  different 
response  may  be  obtained  from  some  one  tooth  than  from  the  others. 
Hypercementosis  of  a  particular  tooth  may  be  suspected  if  finding 
the  gum  line  slightly  receded  and  the  tooth  attachment  unusually 
firm;  if, in  addition,  vague  gnawing,  heavy  dental  pains  have  persisted 
at  intervals  over  a  long  period,  the  diagnosis  is  probable.  It  is  only 
certain  when  tapping  upon  the  tooth  brings  on  a  paroxysm  of 
neuralgia,  or  a  radiograph  actually  exhibits  the  hypertrophic 
growth.  The  remedy  is  extraction.  Any  root  fragment  left  unex- 
tracted  may  perpetuate  the  reflex  disorder.  The  writer  has  recently 
treated  a  case  of  neuralgia  due  to  a  lingual  root  of  a  left  upper  first 
bicuspid  which  was  retained  in  the  gum  after  extraction.  The  gum 
had  healed  perfectly  over  it.  It  was  only  discovered  by  the  use  of 
the  a:;-rays. 

Painful  affections  referred  to  the  neighboring  region  of  the  affected 
tooth,  or  diffused  through  the  distribution  of  the  corresponding 
nerve  trunk,  or  to  the  eye  or  ear,  may  accompany  the  process  of 
resorption  of  the  roots  of  permanent  teeth.  Gillman^  records  a  case 
where  facial  paralysis  disappeared  upon  extraction  of  a  tooth  which 
had  long  been  the  seat  of  disturbance  and  which,  upon  extraction, 
revealed  resorption  of  its  root.  In  these  obscure  cases  a  radiograph, 
if  taken  at  once,  will  be  a  great  aid  in  the  exclusion  or  diagnosis  of 
pericemental  and  root  abnormalities. 

All  of  the  acute  or  chronic,  septic  or  non-septic,  inflammations  of 
the  pericementum  may  give  rise  to  reflex  pains.  The  most  common 
causes  of  the  reflex  pains  are  found  in  that  stage  of  pericemental 
irritation  which  antedates  acute  septic  apical  pericementitis,  prob- 
ably a  granuloma.  Unless  an  exacerbation  of  the  reflex  disorder, 
or  symptoms  referable  to  that  region,  be  induced  by  pressiu'e  or  per- 
cussion on  the  tooth,  a  causal  relationship  is  only  made  out  by  either 
relieving  an  existing  dental  disorder  (for  example,  finding  and  curing 
an  incipient  apical  abscess  due  to  moist  gangrene),  a  radiograph  for 
granuloma,  or  extracting  the  teeth. 

Cases  of  ovarian  and  uterine  neuralgia  and  sciatica  and  cases  of 
obstinate  pains  in  the  knee,  toes,  and  fingers  have  been  traced  to 
dental  irritation  of  some  one  of  the  varieties  named,  the  proof  of 
association  being  disappearance  of  the  pain  with  loss  of  the  tooth. 
Here  the  probable  connection  is  focal  infection  rather  than  a  reflex 
neurosis. 

1  Boston  Medical  and  Surgical  Journal,  1867. 


712  REFLEX  NEUROSES 

IMPACTED  TEETH  AS  A  CAUSE  OF  NEURALGIA. 

Neuralgia  of  varying  degrees  of  severity  is  a  common  accompani- 
ment of  impacted  teeth.  It  is  most  frequently  noted  in  connection 
with  eruption  of  the  lower  third  molars,  not  only  because  this  tooth 
is  the  one  most  frequently  impacted,  but  because  of  the  anatomical 
relations  of  its  roots  with  the  inferior  dental  nerve. 

In  the  milder  forms  of  impaction,  those  in  which  eruption,  though 
delayed,  is  subsequently  completed,  the  pains  are  commonly  local- 
ized and  associated  with  but  occasional  attacks  of  rigidity  of  the 
masseter  muscles.  If,  however,  the  crown  present  horizontally  or 
nearly  so,  and  its  progress  is  arrested  by  impaction  against  the 
posterior  wall  of  the  lower  molar,  or  if  its  progress  be  arrested  by 
permanent  imprisonment  of  the  advancing  crown  between  the  pos- 
terior surface  of  the  second  molar  and  the  base  of  the  coronoid 
process,  not  only  may  intense  local  pains  be  induced,  but  severe 
reflex  disturbances  of  both  a  sensory  and  motor  character  may  occur. 
In  some  of  these  cases  root  formation  is  completed,  although  the 
crowm  of  the  tooth  does  not  advance,  in  which  case  compression  of 
the  inferior  dental  canal  and  its  contents  may  occur  and  .cause  grave 
reflex  disturbances.  The  local  irritation  about  the  root,  due  to  root 
growth,  may  excite  continued  constructive  action  by  the  peri- 
cementum, and  the  hypertrophic  growth  in  its  turn  may  be  the 
source  of  reflex  neuralgias. 

Complete  imprisonment  of  the  entire  tooth  has  been  found  to  be 
the  exciting  cause  of  facial  neuralgias,  for  the  cure  of  which  extensive 
surgical  operations  have  been  performed. 

Impacted  cuspids  and  other  teeth  may  excite  no  other  symp- 
toms than  reflex  neuralgia.  The  possible  connection  between  an 
impacted  tooth  and  neuralgia  is  made  out  after  excluding  other 
dental  causes,  when  it  may  be  observed  that  one  or  more  of  the 
permanent  teeth  are  absent  from  the  dental  arch,  at  dates  long  after 
their  normal  time  of  eruption. 

A  condition  equivalent  to  partial  impaction,  in  which  dental  irri- 
tation may  be  the  source  of  reflex  neuralgia,  is  seen  when  the  teeth 
are  crowded  into  arches  too  small  for  their  accommodation.  During 
the  period  of  eruption  severe  maxillary  pains  may  recur  at  intervals. 
The  diagnosis  is  by  means  of  the  a;-rays.  The  production  of  insanity 
as  a  reflex  condition  has  been  discussed  on  page  128. 

PHANTOM  ODONTALGIA. 

This  is  a  form  of  neuralgia  in  which  symptoms  similar  to  tooth- 
ache appear  in  the  edentulous  jaws  or  in  locations  from  which  teeth 


PHANTOM  ODONTALGIA 


713 


have  been  extracted.  The  name  was  appUed  by  J.  Foster  Flagg. 
It  seems  to  be  due  to  the  compression  of  nerve-endings  by  dense 
bone.  It  may,  of  course,  be  a  reflex  neurosis  from  some  other  focus 
of  pulp  or  pericemental  or  nerve  trunk  irritation.  Attention  has  been 
called  to  a  possible  latent  focal  infection  left  upon  extraction,  a  granu- 
loma not  having  been  removed.  This  would  be  found  by  the  surgeon 
as  a  cavity  rather  than  a  dense  bony  whorl. 

Fig.  688 


The  arrow  points  to  a  dark,  three-sided  shadow — a  bone  "whorl."  The  X  on  the 
shadow  is  caused  by  a  scratch  on  the  negative.  (Radiograph  by  Pancoast.  Courtesy 
of  H.  R.  Raper.) 


Any  history  obtainable  of  a  previous  local  inflammation  should 
be  obtained,  and  if  the  pain  is  localized  in  any  spot  the  bony  tissue 
may  be  broken  up  by  operation  with  a  view  to  removal  of  such  a 


714  REFLEX  NEUROSES   ■ 

cicatricial  inclusion  of  nerve  terminals.  At  least  in  troublesome 
cases  such  a  simple  operation  is  admissible.  Cryer  reports  successful 
operations  for  removal  of  "bone  whorls,"  the  cause  of  neuralgia 
(see  Fig.  688). 

PARALYSIS  OF  THE  SENSORY  TRACTS. 

The  operation  of  extraction  and  occasionally  disease  of  the  pulp 
and  pericementum  have  produced  a  temporary  paralysis  of  a  branch 
of  the  fifth  pair  and  loss  of  sensation  in  the  lip  or  cheek  may  result. 
So  far  as  observed  the  cases  are  of  not  more  than  a  few  months' 
duration  and  may  be  ameliorated  by  massage,  either  passive  or 
vibratory  or  by  faradization. 

MOTOR  DISTURBANCES  FROM  DENTAL  DISEASES. 

Motor  disturbances  due  to  dental  irritation  may  occur  as  recurrent 
or  persistent  contraction  or  paralysis  of  muscles,  together  with  more 
or  less  chorea;  in  rare  instances  epilepsy  and  hystero-epilepsy. 
Twitching  of  muscles  of  the  affected  side  of  the  face,  ranging  from 
slight  affection  of  the  occipitofrontalis  or  orbicularis  palpebrarum 
to  recurring  spasm  of  the  elevators  and  depressors  of  the  lower  lip, 
are  far  from  uncommon  phenomena  attendant  upon  pulp  and  peri- 
cemental diseases.  In  one  case  mentioned  by  Guilford^  a  pulp 
nodule  was  the  cause  of  tic  douloureux  (painful  muscular  contrac- 
tions) of  two  years'  standing.  Varney  Barnes  cites  a  case  of  "  blinking 
of  the  eyes,"  caused  by  an  impacted  tooth.^  A  case  of  recurrent 
epileptic  attacks  was  proven  due  to  a  tooth  brush  bristle  forced  into 
the  gum.^ 

Contraction  of  the  masseter  muscle  is  a  common  accompaniment 
of  retarded  eruption  of  the  lower  third  molar,  which  may  be  inten- 
sified until  the  condition  is  fitly  termed  trismus,  in  some  cases  of 
partial  impaction  of  the  teeth.  Partial  trismus  has  been  found  due 
to  a  general  overcrowding  of  the  dental  arch.^  Records  of  cases  of 
torticollis,  due  to  dental  diseases,  are  also  given  by  Brubaker,  under- 
stood now  as  probably  due  to  focal  infection  and  as  of  rheumatic 
character. 

Cases  of  facial  paralysis,  and  cases  of  paralysis  of  one  arm,  of 
paraplegia  and  hemiplegia,  and  even  of  general  paralysis,  have  been 
noted  as  disappearing  after  the  extraction  of  diseased  teeth.    It  is 

'  Private  communication.  *  Raper,  Items  of  Interest,  August,  1912,  p.  575. 

»  Dental  Cosmos,  1910,  p.  594. 

^  Brubaker,  American  System  of  Dentistry. 


MOTOR  DISTURBANCES  FROM  DENTAL  DISEASES        715 

noteworthy  that  in  these  cases,  as  well  as  in  several  cases  of  tetanus 
recorded,  the  probability  of  an  infection  entered  into  the  patho- 
genesis of  the  nervous  diseases. 

Stellwagen^  records  a  case  where  symptoms  of  partial  hemiplegia 
followed  upon  the  operation  of  capping  the  pulps  of  two  molar  teeth; 
the  symptoms  disappeared  promptly  upon  extraction  of  these  teeth. 
A  case  of  facial  paralysis  followed  extraction  of  seven  roots  upon  one 
side.  It  was  successfully  treated  by  eight  applications  of  a  weak 
galvanic  current  .^  Facial  paralysis  has  also  followed  the  eruption 
of  teeth,  as  of  a  second  molar.  Infantile  paralysis  has  also  been 
caused  by  dentition  (see  page  75). 

Cases  of  insanity  arising  from  dental  diseases  have  been  recorded; 
they  were  both  maniacal  and  melancholic.  In  several  of  them  a 
restoration  to  a  normal  mental  state  followed  promptly  upon  removal 
of  the  offending  teeth.  In  some  of  these  cases  a  preexisting  maxillary 
neuralgia  directed  attention  to  the  teeth  as  possible  sources  of  the 
nervous  diseases. 

Dr.  E.  Ballard  Lodge^  reports  a  case  from  the  practices  of  Drs. 
Upson  and  Stephan  in  which  a  lady  had  suffered  from  acute  melan- 
cholia and  insomnia.  A  radiograph  revealed  an  impacted  upper 
third  molar  pressing  against  the  distal  side  of  the  second  molar. 
Extraction  effected  a  cure.  Upson*  reports  a  number  of  like  cases, 
as  well  as  some  due  to  pulp  and  pericemental  disease.  The  local 
conditions  were  painless. 

Cases  of  deafness  have  been  recorded  due  to  diseases  of  both  pulp 
and  pericementum,  notably  to  hypercementosis.  Deafness  which 
has  persisted  for  a  long  period  has  been  markedly  lessened  by  the 
extraction  of  teeth  the  seat  of  disease.  Cases  of  suppurative  otitis 
media  have  been  regarded  as  having  pathological  association  with 
septic  diseases  about  the  teeth,  from  the  fact  that  the  aural  trouble 
subsided  immediately  after  extraction  of  the  diseased  teeth  (prob- 
ably due  to  focal  infection). 

Sensory  disturbances  of  the  eye,  associated  with  dental  diseases, 
have  been  alluded  to;  in  addition  to  these,  grave  structural  and 
functional  diseases  of  the  eye,  traceable  to  dental  causes,  have  been 
recorded,  such  as  motor  and  trophic  disorders.^  Among  the  latter 
may  be  mentioned  corneal  inflammation  and  ulceration  and  phlyc- 
tenular conjunctivitis.  These  are  probably  due  in  part  to  reflex 
trophic  disturbances,  but  possibly  to  focal  infection. 

1  Private  communication.  ^  Griefswald:  Cosmos,  1906,  p.  356. 

»  Dental  Simimary,  1908.  *  Dental  Cosmos,  1910,  p.  526. 

6  See  Brubaker,  American  System  of  Dentistry,  vol.  iii,  for  very  full  and  detailed 
discussion  of  these  subjects. 


716  REFLEX  NEUROSES 

Irregular  paralyses  of  the  third,  fourth,  and  sixth  nerves  of  the 
aflfected  side  have  been  noted. 

Amblyopia  and  functional  blindness  without  retinal  conditions 
to  account  for  it  have  been  found  to  arise  from  notably  advanced 
degenerative  changes  in  the  dental  pulp,  sight  returning  to  the  eye 
after  loss  of  a  diseased  tooth.  DeWitt^  records  a  most  instructive 
case  where  temporary  blindness  was  associated  with  septic  apical 
pericementitis,  disappearing  after  evacuation  of  the  abscess  and 
reappearing  when  secondary  inflammatory  action  arose  in  the  peri- 
cementum. The  ocular  affection  disappeared  permanently  and  almost 
entirely  with  the  loss  of  the  tooth.  Whether  this  was  a  neurosis  or  a 
focal  infection  is  in  doubt.  The  history  of  this  case  illustrates  the 
important  causal  relationship  of  reflex  disturbances  with  late  pulp 
degenerations,  for  the  blindness  arose  two  months  after  some  teeth 
were  filled,  and  existed  for  twelve  years  before  the  septic  apical 
pericementitis  appeared.  (In  this  case  probably  a  granuloma  was 
the  intermediate  condition.) 

Trophic  Disturbances  Following  Dental  Diseases. — Two  cases  of 
localized  alopecia  (loss  of  hair)  have  been  reported,-  obstinate  during 
the  dental  disease  and  cured  by  the  cure  of  a  pulpitis  in  one  case 
and  extraction  of  a  root  for  suppurative  pericementitis  in  the  other. 
Such  cases  show  a  vasomotor  disturbance  in  the  distant  part.  Infec- 
tion transference  from  a  septic  living  pulp  is  claimed  by  Price.^ 

DENTAL  PAIN  ARISING  FROM  OTHER  THAN  DENTAL  SOURCES 

Conditions  of  pain  the  reverse  of  those  discussed — i.  e.,  pain 
definitely  or  indefinitely  located  in  teeth  which  exhibit  no  morbid 
conditions  whatever — demand  occasional  attention  at  the  hands  of 
the  dentist. 

Chronic  malarial  poisoning,  as  stated  in  the  beginning  of  this 
chapter,  may  give  rise  to  periodical  attacks  of  maxillary  neuralgia, 
As  in  the  gouty  cases,  the  constitutional  cause  of  the  disturbance  is 
made  clear  through  the  therapeusis  most  effective,  viz.,  the  periodical 
recurrence  of  the  pain  leads  to  the  inference  of  a  malarial  origin,  and 
to  the  administration  of  quinin.  Anemia  and  other  conditions  in 
which  there  is  accumulation  of  products  of  metabolism  also  cause  it. 

Syphilitic  pains  in  the  jaws  have  a  pericemental  character,  and 
other  evidences  of  syphilis  are  present  which  point  to  a  diagnosis. 

Pains  in  or  about  the  teeth  are  occasional  accompaniments  of 

*  Quoted  by  Brunton,  Disorders  of  Digestion. 

2  Mounier:  Le  Laboratoire,  1907. 

^  Lecture  on  Focal  Infections,  Pennsylvania  State  Dental  Society,  1917. 


DENTAL  PAIN  FROM  OTHER  THAN  DENTAL  SOURCES     717 

diseases  of  the  brain  or  its  vessels,  and  of  pregnancy  or  diseases  of 
the  uterus,  kidneys,  and  bladder. 

Disease  in  any  portion  of  the  fifth  cranial  nerve  may  cause  pain 
referred  to  the  teeth,  for  example,  inflammation  of  the  nerve  trunk, 
a  tumor  in  the  nerve,  or  a  tumor  pressing  upon  the  nerve  trunk, 
or  a  portion  of  fractured  bone  so  pressing,  or  a  cicatrix  contracting 
upon  a  nerve. 

Dental  pain  during  pregnancy,  without  any  direct  evidence  of 
dental  disease,  is  relatively  common. 

Disorders  of  the  lower  bowels,  causing  constipation,  may  give  rise 
to  pain  referred  to  one  or  more  teeth,  the  pain  ceasing  promptly 
upon  the  administration  of  an  active  evacuant. 

Influenza  occasionally  produces  antral  empyema  or  neuralgia  about 
the  dental  region  as  one  of  its  sequelae. 

Pain  may  appear  in  one  or  more  teeth  either  with  or  without 
association  with  pain  about  the  maxillae  or  tenderness  at  the  foramina 
of  emergence.  If  there  be  possible  causes  in  defective  teeth  or  teeth 
with  fillings  in  which  pulp  irritation  is  a  possibility,  there  may  be 
difficulty  of  diagnosis.  There  may  be  a  history  of  an  attack  of 
influenza  or  even  of  coryza,  with  the  common  variety  of  which 
dental  pains  are  often  associated.  Abscess  in  the  maxillary  sinus 
or  other  sinuses  may  do  the  same. 

It  may  occur  after  influenza  has  seemed  to  have  disappeared.  The 
pain  is  at  first  generalized  over  the  entire  head,  but  gradually  local- 
ized in  one  or  several  upper  teeth,  more  frequently  in  the  second 
molar,  occasionally  the  bicuspids.  It  sometimes  is  so  severe  that 
the  patient  thinks  an  abscess  is  forming. 

There  is  almost  always  pain  in  the  molar  region  when  pressure  is 
made  upon  the  inner  alveolar  portion  of  the  hard  palate,  and  sensi- 
tivity of  the  external  alveolar  region. 

For  the  pseudoodontalgia  Roy  recommends  a  capsule  containing 
the  following: 

IJ — Antipyrin gr.  vij 

Quinine  hydrobromid gr.  iij 

Sodium  bicarbonate gr.  iij 

Sig. — One  dose.    Increase  and  prescribe  four  times  a  day. 

Locally  he  recommends: 

i;^— Mentholis gr.  x 

Acidi  borici 3iij 

Vaselini 5j— M. 

Sig. — A  small  portion  to  be  applied  within  the  nostrils  on  rising  and  retiring. 

Treatment  of  Facial  Neuralgia. — The  cause  should  be  sought  for, 
and,  if  possible,  removed.    If  due  to  disease  of  the  teeth,  these  should 


718  REFLEX  NEUROSES 

be  relieved;  if  due  to  eye  disease,  or  other  cause,  this  should  receive 
attention.  Should  one  not  discover  the  cause,  yet  desire  to  afford 
a  relief  pending  its  discovery,  the  accepted  remedies  antipyrin, 
acetanilid,  and  phenacetin,  combined  with  caffein  or  the  bromids, 
are  useful. 

I^ — Antipyrini  (vel  phenacetini  vel  acetanilidi)      .      .      .      .      3J 

Caffeinse  citratia gr.  x 

Potassi  bromidi Siij — M. 

Ft.  in  chart  No.  x. 

Sig. — One  every  thirty  minutes  untU  relieved.     (Hare.) 

If  the  patient  be  constipated,  the  bowel  should  be  freed  of  toxic 
substances  by  the  use  of  castor  oil,  repeated  as  necessary.  Castor 
oil  in  small  doses  is  antineuralgic. 

In  obstinate  neuralgia  and  other  painful  affections  with  unremov- 
able cause,  the  application  of  the  a;-rays  has  been  urged  by  Morton 
as  highly  efficacious  in  relieving  pain,  often  for  a  considerable  time. 
The  blue  ray  is  also  used.  A  remedy  of  exceedingly  simple  nature 
was  introduced  by  Verge  and  Pitres  in  1902.  It  consists  of  injecting 
into  the  mucous  membrane  or  skin,  about  where  the  pain  seems  to 
originate,  1  c.c.  of  alcohol  (85  per  cent,  plus  1  per  cent,  cocain  is 
preferred  by  Lenson)  at  the  temperature  of  60°  C.  by  means  of  a 
hypodermic  syringe.    Asepsis  must  be  provided  for. 

A  slight  humming  sensation  and  swelling  of  tissue  occurs  about  the 
area  of  injection.  The  pain  disappears  for  a  long  period  after  one 
or  two  injections  a  week  apart. 

Dr.  H.  I.  Patrick^  recommends  the  injection  in  trifacial  neuralgia 
not  dependent  upon  recognizable  conditions  as  preferable  in  the 
middle  aged  and  aged  to  the  Gasserian  operation,  and  sets  forth 
the  landmarks  as  well  as  the  conditions  for  the  operation. 

The  Gasserian  ganglion  has  also  been  injected  with  alcohol  with 
apparent  satisfaction,  and  is  less  serious  than  radical  operation. 

A  deep  injection  into  the  nerve  trunks  has  high  medical  indorse- 
ment. A  case  in  which  the  face  became  black  on  the  side  of  injec- 
tion was  also  followed  by  relief  and  subsidence  of  the  congestion. 
The  method  has  been  objected  to  by  some.  It  has  been  recorded 
that  myosis,  and  prickly  or  tingling  sensation  or  paralysis  of  the  part 
or  nearby  muscles  of  temporary  nature  are  by-effects.  Injection 
of  the  nerve  trunk  with  dilute  osmic  acid  has  been  practised  by 
surgeons. 

Strychnin  in  fairly  large  doses  has  been  employed  under  medical 
supervision.  When  the  cause  cannot  be  determined  the  nerve  itself 
may  be  resected.     These  are  measures  in  the  hands  of  surgeons. 

1  Journal  of  the  American  Medical  Association,  January  20,  1912. 


CHAPTER  XXIV. 

INFECTIONS  OF  AND  FROM  THE  MOUTH. 

Inflammations  of  various  sorts  may  appear  in  or  about  the  moutli 
as  well  as  certain  symptoms  regarded  as  pathognomonic  of  certain 
systemic  diseases.  The  dental  diseases  involving  oral  inflammations 
are  to  be  so  classed,  but  have  been  separately  described.  Here  various 
forms  of  stomatitis  not  distinctlv  dental  will  be  dealt  with. 


STOMATITIS. 

Definition. — By  stomatitis  is  meant  an  inflammation  of  the  mucous 
membrane  of  the  mouth.  If  secretion  is  markedly  increased  it  may 
be  termed  catarrhal  stomatitis. 

Varieties. — It  may  be  localized,  as  in  marginal  gingivitis,  or  be 
diffuse;  and,  again,  be  accompanied  by  localized  tissue  destructions — 
ulcerations;  the  character  of  the  ulceration  differs  according  to  its 
probable  causes. 

Occurrence. — Most  of  these  diseases  belong  to  the  period  of  child- 
hood, although  localized  ulcerative  stomatitis  may  appear  in  the 
adult. 

{Simple. 
Infective 


Catarrhal  stomatitis 


Local 


^  Symptomatic 


Eruptive  fevers. 
Syphilis. 
Tuberculosis. 
Tj^hoid  fever. 

Drug  action 


(Fermentations. 
Diphtheria. 
Gonorrhea. 


lodids. 

Mercury. 
Lead. 
Pilocarpin,  etc. 


Ulcerative  stomatitis 


Local 


Symptomatic 


'  Aphthae. 
Thrush. 

Noma  and  gangrenous  stomatitis. 
Herpes. 

Syphilis  (primary). 
Gonorrhea. 
Vincent's  angina. 
Stomatitis  epizootica. 
Actinomycosis. 
Ludwig's  angina. 


j  Syphilis 
[  Scurvy. 


/  Secondary. 
\  Tertiary. 

(719) 


720  INFECTIONS  OF  AND  FROM   THE  MOUTH 

Causes. — The  causes  of  stomatitis  are  so  many  and  varied  as  to 
suggest  a  classification  under  heads  according  to  assignable  causes. 
While  it  is  true  that  bacterial  infection  has  not  been  shown  to  be  a 
direct  cause  of  all  of  these  conditions,  some  degree  of  causal  relation- 
ship is  probable  in  all  of  them.  The  disease  may,  however,  be 
included  under  two  heads  according  as  they  are  or  are  not  localized, 
and  necrotic.  The  less  localized  cases  appear  as  a  diffuse  catarrhal 
affection,  affecting  wide  areas  of  the  oral  mucous  membrane;  the 
others  appear  as  spots  of  localized  tissue  destruction  attended  by 
surrounding  hyperemia. 

Simple  Local  Catarrhal  Stomatitis. — The  general  symptoms  of 
catarrhal  inflammation — heat  and  swelling,  with  deepened  color  of 
the  mucous  membrane,  followed  by  increased  secretion  and  exuda- 
tion— attend  several  types  of  oral  irritation,  such  as  the  irritation 
induced  by  erupting  teeth,  particularly  of  the  deciduous  teeth.  A 
transient  eruption  may  appear  in  some  cases.  Inflammation  of  any 
degree  may  follow  the  taking  into  the  mouth  of  caustic  chemical 
substances,  such  as  caustic  alkalies,  mineral  acids,  carbolic  acid,  etc. 
Other  irritant  drugs  and  very  hot  fluids  may  produce  similar  results. 
General  catarrhal  stomatitis  is  a  frequent  aftection  of  confirmed 
smokers,  and  of  drinkers  of  distilled  liquors. 

The  cure  of  these  conditions  consists  in  the  removal  or  neutrali- 
zation of  the  cause,  and  the  use  of  local  sedatives  and  antiseptics  to 
allay  irritation  and  prevent  infection.  The  most  effective  method 
of  treating  the  inflammatory  condition  is  by  antiseptic  sprays,  such 
as  diluted  Dobell's  solution,  followed  by  sprays  of  strong  solutions 
of  potassimn  chlorate.  If  much  pain  exist,  phenol-sodique  is  an 
admirable  sedative  antiseptic,  used  in  10  to  20  per  cent,  solution,  as 
a  spray.  A  simple  stomatitis  may  be  caused  by  digestive  disturbances 
(see  below). 

Infective  Local  Catarrhal  Stomatitis. — This  in  some  degree  is  a 
common,  perhaps  the  necessary,  antecedent  condition  to  many  of 
the  ulcerative  forms  of  stomatitis.  It  is  probable  that  many  of  the 
cases  of  stomatitis  found  in  infants,  children,  and  adults  are  due  to 
unusual  fermentations  occurring  in  the  mouth.  Children  whose 
nursing  bottles  are  not  kept  clean;  those  who  at  a  later  age  suffer 
from  neglect  of  the  teeth  and  from  the  effects  of  improper  food: 
adults  in  whose  mouths  dental  disease  is  widespread,  and  whose 
oral  hygiene  is  very  faulty;  all  exhibit  abnormal  conditions  of  the 
oral  mucous  membrane— more  or  less  swelling,  softness,  and  deepened 
color  of  the  mucous  membrane,  a  coated  tongue,  and  offensive 
breath,  with  an  increase  of  oral  secretions. 


STOMATITIS  721 

The  complexus  of  oral  symptoms  is  commonly,  and  also  by  the 
general  practitioner,  regarded  as  symptomatic  of  gastric,  intestinal, 
and  hepatic  disorders,  as  doubtless  it  is,  but  the  causal  relation- 
ship is  in  many  cases  probably  the  reverse  of  that  implied  in  such 
opinions,  for  it  is  probable  that  the  disturbances  of  digestion  are 
fermentative  in  character,  and  the  organisms  causing  them  find  their 
way  to  the  stomach  from  the  mouth,  which  was  first  affected.  The 
treatment  of  this  condition  consists  in  the  correction  of  its  causes, 
their  non-repetition,  and  the  continued  use  of  oral  antiseptics. 

Symptomatic  Catarrhal  Stomatitis. — Stomatitis  in  its  catarrhal 
form  usually  accompanies  the  early  and  later  stages  of  the  eruptive 
fevers,  scarlet  fever,  smallpox,  etc.  In  scarlet  fever,  smallpox,  and 
measles  e\'idences  of  infection  of  the  oral  mucous  membrane  by  way 
of  the  blood  exist  and  the  inflammatory  reaction  is  pronounced. 

Catarrhal  stomatitis  is  one  of  the  manifestations  of  secondary 
and  tertiary  syphilis,  antedating  the  appearance  of  tissue  necrosis 
(ulcerations) . 

More  or  less  catarrhal  stomatitis,  confined,  it  may  be,  to  the 
mucous  membrane  of  the  gums,  is  common  in  the  mouths  of  phthi- 
sical patients;  tubercular  ulcers  may  arise  or  threaten.  In  some 
cases  the  palate  has  been  perforated.  Curtis  states  that  these  are 
usually  fatal. 

The  stomatitis  of  typhoid  fever  may  be  regarded  as  an  almost 
essential  feature  of  the  disease. 

The  effects  of  drug  elimination  by  the  oral  tissues  have  been 
already  discussed  (see  page  568  and  572). 

Mercurials  in  excess  produce  gingivitis  with  puffy  gums  which 
bleed  readily;  there  is  coated  tongue,  fetid  breath  in  marked  cases, 
swollen  tongue  and  cheeks,  and  exfoliation  of  the  teeth.  The  history 
of  administration  of  mercurials,  and,  possibly,  of  syphilis,  as  a  reason 
for  it  affords  a  diagnosis.  The  mercury  should  be  stopped;  atropin 
sulphate,  5  minims  of  a  1 -grain  to  1 -ounce  solution  in  water,  admin- 
istered as  an  antisialagogue  every  four  to  six  hours;  a  5  per  cent, 
potassium  chlorate  solution  in  hydrogen  dioxid  makes  a  useful 
mouth  wash  for  reducing  the  local  inflammation. 

A  case  of  bismuth  poisoning  causing  ulcerative  stomatitis  with 
bright  blue  line  on  both  upper  and  lower  gums  is  reported  by  Blight^ 
as  cured  upon  removal  of  the  bismuth  dressing. 

Ulcerative  Stomatitis. — In  all  probability  these  ulcerations  are 
always  infective.  Like  catarrhal  stomatitis  the  ulcerative  disease  may 
have  only  a  local  significance  or  be  indicative  of  some  general  disease. 

1  British  Dental  Journal,  December  15,  1917,  see  Dental  Cosmos,  May,  1918. 
46 


722  INFECTIONS  OF  AND  FROM  THE  MOUTH 

Ulcerative  Stomatitis  of  Local  Significance. — The  more  usual  or 
infantile  forms  of  these  disorders  are  a  sequel  of  catarrhal  stomatitis, 
at  least  of  an  acquired  debility  of  the  oral  tissues,  and  their  primary 
cause  is,  therefore,  the  cause  producing  a  condition  of  mucous  mem- 
brane which  permits  the  growth  of  infective  organisms.  The  others, 
aphthae,  herpes  labialis,  and  noma,  are  all  probably  due  to  the  action 
of  organisms. 

Aphthae. — This  affection  is  common  in  its  isolated  form,  as  the 
canker  sore.  In  the  catarrhal  stomatitis  of  children,  during  or  after 
dentition,  multiple  sores  frequently  make  their  appearance.  The 
condition  can  best  be  studied  when  it  appears  as  an  isolated  sore  in 
the  mouth  of  the  adult.  The  most  common  situation  of  the  sore  is 
at  the  junction  of  two  mucous  surfaces,  such  as  that  of  the  gum  with 
the  lip  or  cheek,  or  that  of  the  floor  of  the  mouth  with  the  gum  or 
tongue.  Redness  diffused  over  a  limited  area,  followed  by  a  nodular 
hardening,  occurs,  during  which  local  pain  is  annoying;  the  center 
of  the  hardened  area  breaks,  the  epithelium  disappearing,  forming  a 
raw  surface,  wdiich  quickly  acquires  a  rough,  yellowish  white  coating 
which  is  easily  removable.    The  sores  are  very  painful. 

The  mouth  is  usually  otherwise  healthy,  and  there  is  an  absence 
of  associated  throat  and  skin  affections. 

Occasionally  a  lymphatic  gland  is  affected. 

The  notable  fungus  is  the  saccharomyces  albicans;  this  organism, 
when  classified  by  mycologists  as  a  thread  fungus,  was  known  as 
the  oidium  albicans  (Fig.  689).  The  growth  of  this  organism  illus- 
trates forcibly  the  influence  of  soil  on  the  growth  of  fungi.  It 
does  not  occur  in  the  mouths  of  healthy,  well-nourished,  and  clean 
children  with  good  surroundings.  It  is  a  disease  of  childhood, 
particularly  of  nurslings,  and  its  surroundings  is  almost  always 
confined  to  bottle-fed  babies  whose  feeding  bottles  are  kept  in 
an  unclean  condition  though  Brown  considers  traumatism  from 
suckling  a  cause.  Debility  of  the  oral  tissues  is  established  in  conse- 
quence of  the  fermentations  arising  from  the  source  just  named, 
furnishing  a  favorable  condition  for  the  development  of  the  sac- 
charomyces (oidium)  albicans.  The  condition  produced  is  known  as 
thrush.  The  infection  may  be  carried  from  one  child  to  another,  and 
if  the  fungus  be  brought  in  contact  with  an  abraded  mucous  surface 
of  an  adult  it  may  develop. 

The  fungus  burrows  between  the  epithelial  cells  of  the  mucous 
membrane  (Fig.  690),  not  beyond  it.  It  first  appears  in  small  spots 
which  coalesce,  until  large  patches  of  a  membranous-like  growth 
cover  extensive  surfaces,  spreading  by  continuity  to  all  of  the  mucous 
surfaces  associated  with  the  mouth. 


STOMATITIS 


723 


As  bud  fungi  flourish  only  in  media  of  acid  reaction,  the  use  of 
alkahne  washes  is  indicated  in  the  treatment  of  this  condition. 
Wiping  the  patches  with  dilute  phenol-sodique  is  efficacious.     Hy- 


FiG.  689 


Fig.  690 


Saccharomyces  albicans,  thrush  fungus. 
(Miller.) 

drogen  dioxid  or  25  per  cent,  iodin 
in  glycerin  (as  Talbot's  iodogly- 
cerol)  are  also  useful.  Small  spots 
may  be  cauterzed  with  silver  nitrate 
or  phenol  or  trichloracetic  acid. 

This  condition  follows  so  con- 
stantly upon  the  taking  of  very 
indigestible  food,  such  as  lobster, 
Welsh  rarebit,  etc.,  that  acute 
indigestion  must  be  regarded  as 
having  some  causal  relationship 
with  it.  It  is  also  of  frequent  oc- 
currence in  the  mouths  of  dys- 
peptics; that  form  of  gastric  dis- 
turbance attended  with  a  deficiency  of  hydrochloric  acid  in  the  gastric 
juice  appears  to  have  a  constant  association  with  it,  though  it  is  prob- 
ably caused  by  the  oidium  albicans. 

The  appearance  of  ulcerative  stomatitis  in  children,  together  with 
its  treatment,  was  discussed  in  the  chapter  on  Dentition. 

The  general  treatment  of  these  ulcerations  appearing  in  the  mouths 
of  children  is  the  administration  of  a  laxative,  and  the  subsequent 
administration  of  listerine,  gtt.  x,  every  two  hours.  Locally  the 
mucous  membrane  is  to  be  sprayed  with  hydrogen  dioxid,  followed 
by  sprays  of  strong  solutions  of  potassium  chlorate. 

Localized  aphthous  patches  in  the  adult  are  promptly  relieved  by 
the  administration  of  calomel,  gr.  ij,  at  night,  followed  in  the  morning 
by  a  mild  saline.      The  local  sore  is  dried  and  touched  with  pure 


Pavement  epithelium  covered  with 
spores  of  the  oidium  albicans.  (Ch. 
Robin.) 


724  INFECTIONS  OF  AND  FROM  THE  MOUTH 

carbolic  acid.  The  administration  of  alkalies  before  meals,  and 
hydrochloric  acid  after  meals,  usually  remedies  the  gastric  condition, 
unless  it  be  of  long  standing.  A  variety  of  aphthous  sore  is  called, 
from  the  anatomical  situation  of  the  ulcers,  follicular  stomatitis. 
Irritation  and  swelling  of  the  mucous  follicles  in  the  palatal, 
buccal,  and  labial  mucous  membrane  are  accompanied  by  more  or 
less  localized  inflammation;  the  follicles  become  ulcerous,  the  small 
ulcers  having  a  uniform  size.  This  condition  quickly  disappears 
under  the  treatment  advised  for  ulcerative  stomatitis.  An  indica- 
tion of  the  bacterial  origin  of  all  of  these  disturbances  is  seen  in 
the  efficacy  of  antiseptics  used  in  their  treatment. 

Rubber  Sore  Mouth. — A  form  of  stomatitis  is  due  to  artificial 
dentures  resting  upon  the  mucous  membrane,  and  either  by  pressure 
or  light  friction,  or  possibly  by  preventing  radiation  of  heat,  they 
cause  desquamation  of  the  epithelium.  The  part  beneath  the  plate 
assumes  a  more  or  less  reddened  or  ulcerated  appearance.  Vulcanite 
plates  that  are  not  smooth  upon  their  surfaces  of  adaptation  may 
produce  this  physical  irritation,  but  oftentimes  such  surfaces  may 
be  covered  with  infective  mucous  plaques,  so  that  this  may  in  some 
cases  be  an  added  cause.  Plates  often  cause  mechanical  abrasions  at 
the  inner  part  of  the  margins  or  actually  sink  into  the  tissues.  These 
abra;sions  may,  of  course,  be  infected.  To  prevent  this  in  new  plates, 
as  is  likely  and  annoying  to  all  concerned,  the  writer  suggests  to  the 
patient  to  place  a  pencil  mark  on  the  plate  above  the  point  of  irrita- 
tion and  to  remember  whether  "inside"  or  "outside,"  then  to  scrape 
slightly  and  repeat  as  necessary.  A  good  rule  m  finishing  plates  is  to 
"round"  all  sharp  angles. 

Eilestein  has  shown  that  the  use  of  vermillion  colored  vulcanite 
causes  minute  pores  to  appear  in  the  vulcanite  which  harbors  bacteria 
which  may  induce  inflammation  of  the  oral  epithelium.^  The  use  of 
carmme-colored  vulcanite  is  suggested.  The  making  of  smooth  con- 
tact surfaces  is  a  duty. 

Treatment. — The  treatment  consists  of  rest  and  healing  mouth 
washes.    Antiseptics  are  usually  included.     (See  Gingivitis.) 

Stomatitis  Aphthosa  Epizootica.^ — This  is  the  oral  expression 
of  foot-and-mouth  disease  occurring  in  cattle  and  rarely  fatal,  and 
usually  lasting  about  eight  weeks.  The  germ  is  not  fully  determined 
as  yet.  It  is  transferred  by  contact  as  to  hands  of  milkmaids  from 
herpetic  eruptions  on  the  cows  or  from  milk  to  the  mouth.  Herpetic 
eruptions  and  aphthous  ulcers  are  the  condition  produced. 

'  L'Odontologie.    See  Dental  Cosmos,  February,  1911,  p.  248. 
'  Lartschneider:    Dental  Cosmos,  1908,  p.  880. 


STOMATITIS  725 

Equinia  (Glanders)  .—An  infectious  disease  of  cattle  which  may  be 
transferred  to  man,  producing  a  purulent  discharge  from  eyes,  nose, 
and  mouth. 

Diagnosis. — The  diagnosis  rests  upon  the  presence  of  the  bacillus 
mallei  or  the  use  of  mallein  as  a  diagnostic  test  (B^0T^^l)  of  the  disease 
in  nearby  cattle  and  the  prodromata  and  later  presence  of  fever, 
pustules  on  the  mucous  membranes  of  the  lips,  tongue,  and  some- 
times on  the  hard  palate  and  tliroat,  occasionally  between  fingers, 
around  nails,  or  on  nipples.  These  later  burst,  leaving  ulcers  with  a 
grayish-yellow  coating.  The  pustules  dry  up  without  scars  in  the 
second  week.  Brown  states  that  it  may  extend  into  the  system  via 
lymphatics  and  become  chronic  or  even  cause  multiple  abscesses  and 
death  from  toxemia  and  exhaustion. 

Treatment. — The  treatment  rests  upon  antisepsis  in  so  far  as  the 
local  manifestations  are  concerned. 

Diphtheria. — While  the  point  of  first  attack  of  the  diphtheria 
bacillus  is  most  marked  about  the  soft  palate  and  tonsils,  the  false 
membrane  forming  there  and  spreading  to  the  pharynx,  more  or 
less  general  inflammation  of  the  oral  mucous  membrane  also  occiu-s. 
Hare^  highly  commends  aqua  hydro  genii  dioxidi,  in  full  strength,  on 
a  swab  or  1  to  4  per  cent,  of  water  as  a  spray  for  the  local  treatment. 

Gangrenous  Stomatitis,  Noma,  Cancrum  Oris. — In  ill-fed,  ill- 
nourished,  and  ill-kept  cachectic  children,  or  those  having  had  a 
previous  debilitating  acute  infective  disease,  the  debilitation  of  the 
oral  tissues  may  exceed  the  grades  given,  and  a  disease,  probably 
bacterial  in  origin,  may  arise  which  leads  to  widespread  necrosis  of 
the  cheeks  and  maxillae.  The  condition  is  called  gangrene  of  the 
mouth,  noma,  or  cancrum  oris;  the  latter  term  has  been  applied  to 
the  less  severe  varieties.  Leukemia  is  an  occasional  debilitating  cause. 
(Brown.), 

This  disease  may  make  its  appearance  as  an  ulcer  at  the  junction 
of  cheek  and  gum;  in  other  cases  a  severe  stomatitis  arises  without 
a  primary  ulcer.  A  greater  or  less  extent  of  the  cheek  acquires  a 
board-like  hardness,  becoming  livid;  the  overlying  mucous  mem- 
brane breaks,  exhibiting  a  large  slough.  The  necrosis  extends  toward 
cheek  and  jaw,  destroying  further  tissue.  The  sloughs  undergo 
putrefactive  decomposition,  emitting  a  stench.  The  destruction  of 
tissue  may  be  arrested,  or  may  proceed,  destroying  in  a  few  days 
the  entire  cheek  and  bony  tissues.  In  the  more  severe  cases  the 
disease  is  almost  invariably  fatal,  because  the  extent  of  the  tissue 
destruction  bears  a  constant  relation  to  the  underlying  debility  of 

1  Practical  Therapeutics. 


726 


INFECTIONS  OF  AND  FROM  THE  MOUTH 


the  patient.  It  will  be  seen  that  the  disease  resembles  malignant 
pustule  or  carbuncle  in  se^^eral  of  its  features.  The  etiology  is  uncertain. 

Schimmelbusch'  found  a  bacillus  (pure  culture)  upon  the  borders 
of  the  necrosis  which  may  prove  pathogenic  of  noma. 

Hillesen  obtained  a  diplococcus  which  developed  in  pure  culture, 
produced  noma  in  an  animal  into  which  it  was  injected,  and  from 
the  lesion  a  pure  culture  of  it  was  obtained  which  in  like  manner  was 
put  through  four  animals. ^ 

These  cases  are  purely  medical ;  so  that  their  full  discussion  is  not 
warranted  in  these  pages.  The  principle  of  treatment  is  to  improve 
the  general  condition  of  the  child,  destroy  the  probable  infection 
in  the  borders  of  the  still  vital  tissue  by  cauterization,  and  promote 
sloughing  of  the  necrosed  tissue  by  the  use  of  antiseptic  applications. 

Fig.  691 


Noma.     (J.  Lewis  Smith.) 


Dr.  L.  Fisher  (New  York)  reported  a  case  upon  the  inside  of  the 
cheek,  cured  by  applications  of  ichthyol  in  lanolin  four  times  a  day 
over  the  entire  area.^ 

The  Eruptive  Fevers. — Hyde  and  Montgomery  describe  the  fol- 
lowing oral  symptoms  associated  with  various  diseases  having 
eruptive  dermatitis  as  phenomena: 


1  Miller:  Dental  Cosmos,  September,  1891. 

2  Dental  Cosmos,  1908,  p.  180. 


3  Ibid.,  1902. 


STOMATITIS  727 

Scarlatina. — The  mucous  surfaces  of  the  mouth  and  fauces  are 
engorged  tumid,  reddened,  and  often  covered  with  deep  reddened 
puncta.  The  tongue  is  coated  with  a  white  fur  over  the  fihform 
papillae.  This  is  first  partly  lost,  giving  red  puncta  and  a  white 
background;  when  totally  lost  it  gives  "strawberry  tongue." 

Variola. — ^The  papules  may  appear  over  the  entire  alimentary 
canal.  In  the  mouth  they  lose  their  epithelium,  through  heat, 
moisture,  and  friction.  Reddened  excoriated  surfaces  appear,  over 
which  the  epidermis  is  reformed.     Gangrenous  complications  are  rare. 

Hemorrhagic  Variola  (Effusions  of  Blood  into  Mucous  Surfaces). — 
The  mucocutaneous  orifices  are  crust-covered  and  exude  an  extreme 
fetor.     Blood  may  escape  from  the  mouth. 

Varicella. — The  macular  lesions  may  extend  to  the  surfaces  of  the 
eyes,  mouth,  etc. 

Rubeola  (Measles). — Even  three  days  before  skin  eruptions. 
"Koplik's  spots,"  bluish  white  or  bright  red  with  central  bluish- 
white  punctmn  on  mucous  membrane.  In  period  of  efiloresence  a 
catarrhal  or  eruptive  inflammation.  The  mouth  and  throat  have  the 
eruptions. 

Syphilis. — ^Secondary  eruptions,  later  forming  mucous  patches; 
characteristic  crusts  about  nose  and  mouth  (see  page  732). 

Urticaria. — The  eruption  in  well-marked  cases  may  include  the 
mucous  membranes. 

Angioneurotic  Edema. — ^The  rosy  red  to  livid  edematous  plaques 
may  appear  upon  the  lips  and  pharynx,  producing  at  times  dyspnea. 

Erythema  Scarlatiniforme. — The  mucous  membranes  in  mouth 
and  fauces  may  be  reddened  or  be  denuded  of  epithelium,  but  the 
characteristic  "straw^berry  tongue"  of  scarlatina  is  wanting. 

Erythema  Iris. — The  papules  may  coalesce  and  be  filled  with 
blood  or  hematuria  may  result  with  severe  involvement  of  mucous 
membranes  of  lips  and  mouth,  ulceration  rapidly  ensuing. 

Erythema  Multiforme. — Like  the  iris  variety  the  macules  may  appear 
in  the  mouth. 

Dermatitis  Herpetiformis. — When  affected,  mucous  membrane  of 
mouth  sodden,  macerated,  pustules;  bullge  form  and  rupture,  leaving 
raw  erosions  or  sloughing  patches  of  mucous  membrane;  extremely 
foul  odor. 

Herpes  Simplex. — Herpes  Zoster. — See  page  735. 

Erysipelas. — May  extend  to  mouth,  causing  a  dry,  tumid,  glazed 
appearance. 

Rhinoscleroma. — A  rare  disease;  usually  begins  in  nose;  may  extend 
to  mouth,  with  ulcerative  destruction,  causing  exfoliation  of  the  teeth. 

Pemphigus  Foliaceus. — ^The  mucous  membrane  of  the  mouth  and 
throat  may  be  denuded. 


728  INFECTIONS  OF  AND  FROM  THE  MOUTH 

Pemphigus  Vegetans. — White  patches  followed  by  excoriation  with 
foul  odor  may  occur. 

Drugs  Producing  Stomatitis. — Many  drugs  taken  internally  may 
produce  dermatitis  or  stomatitis  as  a  temporary  efflorescence,  while 
with  some,  as  mercury,  the  impression  is  more  profound  (see  page 
646) ;  with  others  it  is  simply  expression  of  idiosyncrasy,  with  which 
the  oral  tissues  may  or  many  not  take  part. 

lodin  or  bromin  or  their  compounds;  antipyrin  and  others  of  its 
class;  arsenic,  belladonna,  aconite,  carbolic,  nitric,  tannic,  boric,  and 
benzoic  acids;  sodium  benzoate  and  sodium  borate. 

Chloral,  digitalis,  mercury,  opium  and  its  alkaloids,  phosphorus, 
podophyllum,  potassium  chlorate,  castor  oil,  cinchona  and  its  alkaloid, 
quinine,  salicylic  acid  and  salicylates,  strychnine,  tar,  turpentine,  and 
others  of  less  interest  are  mentioned.  Silver  nitrate  internally  given 
may  produce  argjTia  of  the  skin  and  mucous  membranes.  As 
instanced  by  argyria,  the  drug  finds  its  way  to  the  superficial  tissue 
in  which  it  may  produce  irritation.     (Also  see  page  573.) 

SYPHILITIC  AFFECTIONS  OF  THE  MOUTH. 

The  recognition  of  syphilitic  lesions  about  the  mouth  is  of  vital 
importance  to  the  dental  operator,  first,  because  by  the  recognition 
he  may  take  steps  to  prevent  the  carriage  of  infection  to  innocent 
patients;  and  secondly,  that  he  may  avoid  inoculation  of  himself 
by  the  poison. 

In  the  minds  of  many,  syphilis  is  associated  with  the  lower  class  of 
persons,  who  are  confirmed  debauches.  While  it  is  undoubtedly  true 
that  its  prevalence  is  most  marked  in  this  class  of  persons,  it  appears, 
with  horrible  frequence,  in  persons  who  would  be  little  suspected 
of  having  such  infection.  The  operator  is  to  be  guided  in  his  opinions 
and  precautions  in  this  matter,  not  by  the  social  status  of  the  patient, 
but  by  the  nature  of  the  morbid  conditions  existing. 

The  cause  of  syphilis  is  the  traponema  pallidum  discovered  by 
Schaudin  and  Hoffman,  and  present  in  its  lesions,  transmitted  from 
one  person  to  another  directly  or  through  the  medium  of  an  inani- 
mate object  which  has  been  infected. 

The  diagnosis  may  be  made  by  microscopic  examination.  The 
sore  is  washed  and  the  serum  later  exuded  used  to  make  a  smear  on 
a  glass  slide.  Stein  states  that  the  edge  of  the  sore  should  be  scraped 
with  a  sharp  instrument  after  washing,  and  the  serum  collected 
from  that  source,  otherwise  the  treponema  may  not  be  obtained.^ 

I  Dental  Cosmos,  July,  1913,  p.  744. 


SYPHILITIC  AFFECTIONS  OF  THE  MOUTH  729 

This  is  first  dried  in  the  air,  then  stained  with  Hastings'  stain.  After 
a  minute  distilled  water  is  added  until  a  metallic  film  is  formed. 
After  five  minutes  more  they  are  washed  in  running  water  and 
dried.  The  treponema  pallidum  stains  a  faint  blue.^  They  may 
also  be  seen  living  by  aid  of  the  ''dark-field  illuminator."  It  is  said 
to  have  a  slower  motion  and  less  midulation  than  other  oral  spiro- 
chetes. 

Syphihs  is  usually  divided  into  three  stages,  primary,  secondary, 
and  tertiary;  to  these  may  be  added  a  fourth  stage,  viz.,  in  patients 
who  have  been  discharged  as  cured  mild  manifestations  of  disorders, 
particularly  of  the  skin  and  mucous  membranes,  make  their  appear- 
ance from  time  to  time,  and  disappear  promptly  upon  the  adminis- 
tration of  iodids.  The  semen  of  syphilitics  in  the  secondary  period 
is  infectious  to  apes  and  therefore  accounts  for  heredo-s\-philis. 

The  first  stage  of  syphilis — primary  syphilis — consists  in  the  for- 
mation of  the  primary  sore  or  chancre,  and  the  involvement  of  the 
nearest  lymphatic  glands.  Secondary  syphilis  is  attended  by  fever, 
eruptive  inflammations  of  the  skin,  inflammation  and  superficial 
ulceration  of  mucous  structures.  In  tertiary  syphilis  destructive 
inflammation  of  the  skin,  mucous  membranes,  and  connective  tissue 
occurs,  together  with  the  formation  of  specific  tumors — gummata. 

Some  differences  of  opinion  exist  among  syphilographers  as  to  the 
relative  infective  power  of  the  secretions  from  the  several  lesions 
of  syphiHs.  All  are  agreed,  however,  that  the  secretions  from  the 
secondary  lesions  observed  in  and  about  the  mouth  are  highly 
infective.  It  is  the  part  of  prudence  to  regard  all  syphilitic  lesions 
as  infective.  All  these  stages  of  syphilis  may  be  seen  in  the  human 
mouth.  It  is  to  be  remembered  that  if  the  mucous  membrane  of 
the  mouth  be  infected  from  a  mucous  patch  (a  secondary  lesion), 
the  acquired  disease  will  appear,  not  as  a  mucous  patch,  but  as  a 
chancre.  It  is  from  mucous  patches  that  infection  is  most  to  be 
feared. 

Primary  Syphilis  of  the  Mouth. — Causes. — The  primary  lesion 
of  syphilis,  chancre,  when  found  in  the  mouth  is  a  consequence  of 
direct  infection  from  a  syphilitic.  The  infection  occurs  from  contact 
of  the  mucous  surface  of  the  mouth  with  a  syphilitic  lesion  upon 
another  person.  It  has  been  transmitted  by  kissing,  even  with 
an  innocent  person  as  the  intermediary;  it  may  occur  from  using 
a  glass  or  cup  previously  used  by  a  syphilitic,  by  smoking  cigars  or 
cigarettes  which  have  been  made  by  syphilitic  cigarmakers,  who 
have  applied  the  tongue  to  the  tobacco  in  attaching  the  wrapper. 

1  McKee:    Dental  Cosmos.  1909.  p.  1437. 


730  INFECTIONS  OF  AND  FROM  THE  MOUTH 

Dental  instruments  may  be  the  carriers.  Any  of  the  articles  named, 
or  the  contact  of  any  article  which  has  been  in  contact  with  a 
syphilitic  lesion,  if  brought  in  contact  with  an  abraded  mucous  sur- 
face, may  cause  infection.^ 

The  infection  may  be  transferred  from  patient  to  operator  if  the 
fingers  have  any  abraded  surface,  or  if  the  surface  is  broken  acci- 
dentally by  an  instrument.  Dentists  have  been  inoculated  upon  the 
hand.  During  and  since  the  time  of  Hunter  the  use  of  teeth  from 
syphilitic  patients  in  plantation  operations  has  been  a  clearly 
recognized  medimn  of  communication.  A  fair  percentage  of  all 
primary  chancres  appear  within  the  dental  field  either  upon  the 
lips  or  within  the  mouth. 

Appearance  and  Diagnosis. — "The  primary  lesion  of  syphilis 
never  makes  its  appearance  before  ten  days  after  infection;  the 
maximum  period  is  about  ninety  days;  the  average  is  twenty-one 
days."2 

It  usually  appears  as  a  single,  elevated,  hard  papule.  In  cases  of 
oral  infection,  most  frequently  about  the  lips,  the  papule  loses  its 
epithelial  coating  after  some  days.  The  induration  surrounding  the 
papular  mass  increases  until  the  papule,  which  is  now  raw  and  in  a 
process  of  ulceration,  appears  surrounded  by  a  ring  of  cartilaginous 
hardness.  This  induration  is  the  one  distinguishing  feature  of  the 
chancre,  which  is  not  painful.  In  about  a  week  after  the  appearance 
of  the  primary  sore,  swelling  of  the  submaxillary  lymphatic  glands  is 
observed.  In  case  the  chancre  appears  upon  the  tongue,  the  sub- 
hyoid lymphatic  glands  are  swollen.^  Unless  pyogenic  infection  has 
occurred,  the  lymphatic  involvement  is  not  inflammatory,  there 
being  no  pain  present.  In  from  three  to  four  weeks  the  sore  disap- 
pears, leaving  no  signs  of  its  site  in  some  cases;  in  others,  some 
induration  may  persist. 

The  diagnosis  of  this  condition  is  the  important  consideration,  so 
far  as  the  dental  practitioner  is  concerned,  its  treatment  being  the 
province  of  the  medical  practitioner. 

The  elevation  of  the  sore,  its  induration,  and,  if  obtainable,  the 
time  of  inoculation,  are  diagnostic  data.  The  sore  is  single,  as  a 
rule,  and  there  is  hard,  nodular  painless  swelling  of  the  neighboring 
lymphatics.  A  single  ulcer  of  ulcerative  stomatitis  may  in  some 
degree  simulate  the  appearance  of  a  very  small  chancre.  It  may 
exhibit  slight  induration,  but  its  irregular  form,  situation,  painful- 

'  Metchnikoff  and  Roux  found  that  an  ointment  composed  of  10  parts  calomel 
and  20  parts  lanolin,  applied  by  inunction  to  an  intentionally  infected  part,  prevented 
the  appearance  of  syphilitic  infection  if  used  within  one  hour  after  inoculation.  Mer- 
curic chlorid  was.  of  no  avail.     Dental  Cosmos,  1907,  p.  1007. 

-  Gross:    System  of  Surgery.  '  Park's    Surgery. 


SYPHILITIC  AFFECTIONS  OF  THE  MOUTH  .    ?3l 

ness,  and  the  usual  absence  of  lymphatic  involvement,  together 
with  its  prompt  disappearance  after  sterilizing  the  mouth  and  cauter- 
izing the  ulcer,  will  differentiate  the  two  sores.  If  the  chancre  be 
upon  the  tip  or  sides  of  the  tongue,  where  it  is  subjected  to  irrita- 
tion, it  may  become  very  large  and  bear  a  close  resemblance  to 
epithelioma  of  that  organ.  In  epithelioma  there  are  apt  to  be  pains 
of  a  lancinating  character,  the  induration  follow^s  ulceration,  and 
the  ulcer  has  hard  edges  and  often  a  warty-like  growth. 

It  is  a  wise  precaution  to  view  all  sores  about  the  mouth  as  possibly 
infectious.  All  errors  of  diagnosis  in  this  direction  will  be  more  than 
compensated  for  by  the  assurance  of  non-transference  of  infection. 

Secondary  Syphilis  of  the  Mouth. — The  secondary  manifestations 
of  syphilis  may  be  observed  in  and  about  the  mouth,  no  matter  what 
the  location  of  the  primary  lesion  may  have  been;  they  are  the  result 
of  a  general,  not  a  local,  infection.     A  skin  eruption  appears  also. 

Fig.  692 


f^    ii»T"ii"'  . 


Chancre  of  the  lip. 

Secondary  infections  of  the  mucous  tissues  appear  in  from  four 
to  twelve  weeks  after  the  appearance  of  the  primary  lesion.  Sore 
throat,  due  to  inflammation  of  the  mucous  membrane  of  the  pharynx 
and  parts  about,  is  almost  constant;  together  with  syphilitic  hoarse- 
ness, due  to  the  extension  of  the  affection  to  the  mucous  membrane 
of  the  larynx. 

The  appearance  of  copper-colored  areas  upon  some  portion  of  the 
mucous  membrane,  on  the  tonsil,  pharynx,  soft  palate,  lips,  or  bucco- 
labial  surface,  precedes  the  loss  of  epithelium  over  these  surfaces, 
w^hich  soon  occurs,  forming  the  most  virulently  contagious  lesion 
of  syphilis,  the  mucous  patch.  The  patches  become  covered  with 
a  grayish-w^hite,  opalescent,  pasty  covering,  resembling  the  ulcera- 
tions of  non-specific  stomatitis.  So  close  is  the  resemblance  that  a 
differentiation  can  only  be  made  at  times  by  additional  evidences  of 


732  INFECTIONS  OF  AND  FROM  THE  MOUTH 

secondary  syphilis.  Single  patches  may  coalesce,  forming  large, 
irregular  areas  covered  by  a  grayish-white  pellicle.  These  patches 
are  rarely  painful.  Ulcerations  having  ragged,  irregular  outlines 
may  appear  at  the  sites  of  the  original  patches  or  in  other  situations, 
and  exhibit  a  tendency  to  spread.  In  healed  cases  the  cicatrices 
present  a  whitish  pellicle  and  contracted  scar,  indicative  of  old 
healed  ulcers.    In  the  skin  little  pits  and  linear  scars  are  symptomatic. 

The  diagnosis  of  the  condition  is  determined  by  the  history  and 
by  a  discovery  of  other  lesions  of  secondary  syphilis,  iritis,  head- 
ache, neuralgia,  paralysis  of  muscles  of  eye  and  face,  chorea,  brittle, 
cracking  nails  are  often  early  symptoms;^  also  the  lymphatic  glands 
will  be  involved;  skin  eruptions,  falling  out  of  the  hair  (alopecia), 
and  the  areas  of  copper-colored  eruption  upon  the  mucous  mem- 
brane of  the  pharynx  and  soft  palate. 

Hugenschmidt^  has  observed  among  syphilitics,  who  presented  no 
local  lesions,  the  frequent  nocturnal  occurrence  of  indefinitely  located 
dental  pains,  spreading  to  the  palatal  region.  In  case  of  doubt, 
search  for  the  treponema,  or  the  Wassermann  or  Noguchi's  luetin 
reaction  may  be  employed.     (See  works  on  Bacteriology.) 

Smoker's  patches  (leukoplakia)  are  considered  by  some  as  signs  of 
syphilis  but  can  only  be  considered  in  this  connection  if  confirmed 
by  the  Wassermann  test. 

Tertiary  SyphiUs  of  the  Mouth. — The  syphilides  of  the  secondary 
stage  arise  in,  and  are  confined  to,  the  mucous  and  dermal  structures ; 
those  of  the  tertiary  stage  arise  in  the  deep  connective  tissues,  and 
are  frequently  associated  with  periosteum. 

Tertiary  lesions,  as  seen  by  the  dentist,  are  usually  in  the  form  of 
ulcers  of,  first,  the  soft  or  hard  palate,  and  of  the  tongue  or  lips.  In 
the  earlier  stages  hard,  nodular  formations  may  be  noted  as  ante- 
cedents to  the  ulcerations.  Chronic  periostitis  of  the  palatal  processes 
may  occur,  leading  to  the  formation  of  localized  thickenings.  In 
other  cases,  in  the  soft  palate,  upon  the  tongue,  or  in  the  hard  palate, 
localized  swellings  may  occur,  having  a  livid  red  appearance;  the 
overlying  mucous  membrane  breaks,  establishing  an  ulcer,  which 
may  perforate  the  soft  palate  and  destroy  a  portion  of  the  palatal 
process,  or  form  large  ulcers  on  the  tongue.  The  condition  is  one 
of  gumma.  These  lesions  appear  in  from  two  to  five  years  after  the 
secondary  manifestations. 

Tertiary  Lesions. — The  sight  and  hearing  may  be  affected,  the 
throat  diseased,  causing  loss  of  voice,  necrosis  of  the  bones  and  tissues 
of  the  nose  causing  deformity.     The  brain  or  spinal  cord  affected 

»  E.  Whitney:    Dental  Cosmos,  1911,  p.  524.  ^  Dental  Cosmos,  1892. 


TUBERCULOSIS  OF  THE  MOUTH  733 

may  cause  paralysis,  locomotor  ataxia,  or  loss  of  reason.  These  are 
usually  the  result  of  failure  to  follow  treatment  to  a  conclusion. 

The  tongue  may  have  either  a  localized  or  widespread  parchment 
like  hyperplasia  of  the  mucous  membrane,  and  muscular  tissue  which 
may  cause  it  to  be  become  indented  by  the  teeth,  to  lose  its  papillae, 
and  become  dry  and  red.  Pederseni  calls  attention  to  the  fact  that 
the  indentations  do  not  disappear  when  the  tongue  is  stretched, 
while  if  due  to  ordinary  debility  they  may  do  so. 

Although  there  is  much  doubt  as  to  the  degree  of  infectiveness  of 
these  tertiary  lesions,  precautions  as  to  sterilization  should  be  taken 
as  with  the  primary  and  secondary  lesions.  A  defined,  ragged  ulcer 
occupying  the  hard  or  soft  palate,  which  has  persisted  for  a  long 
time,  should  always  be  viewed  with  suspicion,  and  a  search  be  made 
for  other  evidences  of  syphilis. 

These  ulcerations  appearing  upon  the  side  of  the  tongue  may 
closely  simulate  epithelioma  of  that  organ.  The  confusion  is  increased 
if,  in  consequence  of  the  presence  of  jagged  teeth,  a  continuous 
irritation  is  excited.  Moreover,  leukoplakia  of  the  cheeks,  a  diag- 
nostic sign  of  possibly  incipient  epithelioma,  frequently  accompanies 
tertiary  sj^hilis. 

The  existence  of  tertiary  syphilis  is  of  great  clinical  importance  to 
the  dentist  in  that  a  condition  of  lessened  resistance  of  tissues  is 
established,  and  disease  processes  which  in  the  healthy  person  are 
comparatively  circumscribed,  in  the  syphilitic  run  a  riotous  course. 
A  septic  pericementitis  by  extension  may  involve  a  wide  area  of 
periosteum,  leading  to  extensive  maxillary  necrosis. 

Treatment. — The  treatment  of  syphilis  has  been  largely  by  the 
administration  of  mercury  and  potassium  iodid  for  a  long  period 
until  the  treponemata  shall  have  been  killed  out.  If  not  so  con- 
tinued the  tertiary  lesions  may  reappear  with  serious  results.  The 
latest  development  in  treatment  is  the  use  of  Ehrlich's  preparation 
of  arsenic,  dioxydiamedoarsenobenzol,  "606,"  or  "salvarsan,"  for 
which  positive  claims  as  a  prompt  cure  are  made.  There  is  promise 
of  a  cheap  and  valuable  chemical  remedy  from  the  Rockefeller 
Institute. 

TUBERCULOSIS  OF  THE  MOUTH. 

The  bacillus  of  tuberculosis,  under  favorable  conditions,  develops 
in  the  tissues  of  the  mouth,  producing  its  characteristic  lesions. 
Finding  a  suitable  soil,  such  as  is  furnished  by  the  heredity  which 
predisposes  to  phthisis  pulmonalis,  the  bacillus  may  find  entrance 

1  Dental  Cosmos,  1908,  p.  332. 


734  INFECTIONS  OF  AND  FROM  THE  MOUTH 

to  the  deeper  tissues  from  the  mucous  membrane  of  the  mouth  and 
excite  tuberculosis  in  the  deep  structures,  the  bone,  etc.  A  number 
of  perforations  of  the  hard  palate  have  occurred.  According  to  Curtis 
these  are  usually  fatal.  What  part  is  played  by  local  oral  and  dental 
lesions  in  tuberculosis  of  distant  parts,  by  establishing  pathways 
for  the  entrance  of  the  bacilli  into  the  circulation,  is  at  present 
conjectural,  but  that  such  infections  occur  is  very  probable.  Lupus, 
a  skin  tuberculosis,  may  extend  to  the  mouth  producing  nodules. 

ACTINOMYCOSIS. 

The  condition  produced  by  the  development  of  the  ray-fungus,  the 
actinomycosis,  in  the  lower  jaw  and  cervical  regions  of  cattle  and 
swine — lump- jaw — is  not  unknown  in  human  beings.  It  may  be 
derived  by  chewing  straw  or  grass  in  which  the  ray-fungus  has 
produced  "rust." 

Miller^  gives  203  cases  reported  in  German  medical  literature 
between  1886  and  1891.  In  at  least  120  of  these  cases  the  point  of 
entrance  of  the  fungus  was  found  to  be  in  the  region  of  the  mouth  or 
throat.  Actinomycosis  threads  have  been  repeatedly  found  in  the 
saliva  and  in  carious  teeth,  and  notably  in  the  tonsils.  Whether  the 
path  of  entrance  to  deeper  structures  is  ever  through  carious  teeth 
is  undertermined,  but  certainly  lesions  or  wounds  about  the  mouth 
furnsh  an  entrance.  Padgett  reports  a  case  of  alveolar  ulceration 
following  extraction,  which  proceeded  to  abscess  upon  the  face. 
Bacteriological  examination  showed  the  ray-fungus. 

The  disease  has  yielded  to  the  action  of  sulphate  of  copper,  ^ 
grain,  plus  iodid  of  potassium,  10  grains,  internally  four  times  a  day, 
together  with  local  irrigation  of  0.1  per  cent,  solution  of  copper 
sulphate.^ 

GONORRHEA. 

Cases  of  oral  infection  by  the  gonococcus  of  Neisser  have  been 
reported.  The  oral  mucous  membrane  and  the  gums  may  undergo 
intense  suppuration  with  its  accompaniments.  Fever  and  its  accom- 
paniments may  be  present.  The  e^^es  are  very  subject  to  secondary 
infection  in  an  individual  suffering  from  gonorrheal  urethritis.  The 
hands  are  a  medium  of  transference.  Babes  may  be  directly  infected 
by  the  mother  during  birth,  and  blindness  often  results.  The  law 
now  requires  the  instillation  of  a  mild  solution  of  silver  nitrate  or 
other  antiseptic  as  advocated  by  Crede.     The  diagnosis  can  be  made 

>  Dental  Cosmos,  1891.  2  Brophy:    Dental  Cosmos,  1908,  p.  78. 


HERPES  ZOSTER  735 

by  microscopic  examination  of  the  bacteria  Brown^  cites  a  case  in 
which  the  gonococci  were  found.  Stein  claims  that  endeavor  to  infect 
the  nose  with  gonococci  failed  and  questions  oral  infection  by  them. 
(See  page  610.)  Lederer  in  a  case  of  oral  infection  in  a  patient  with 
urethral  gonorrhea  found  it  by  microscopic  examination  to  be  a  case 
of  Vincent's  angina,  which  see.  Calomel  internally  and  silver  nitrate 
applications,  1  to  250  increased  gradually  to  1  to  50  are  recommended. 
(Brown.) 

HERPES  LABIAUS  (FACIALIS)   (HERPES  SIMPLEX). 

This  consists  of  a  vesicular  eruption  upon  the  lip,  tongue,  mouth, 
cheeks,  or  allae  of  the  nose.  The  vesicles  are  filled  with  a  clear  fluid 
which  soon  discharges.-  An  excoriation  is  left  often  covered  by  a 
light  crust,  which  is  never  followed  by  a  scar.  The  condition  msiy 
cause  little  pain  or  considerable  burning  and  itching.  It  may  accom- 
pany colds,  fevers,  exposure  to  heat,  draughts,  and  gastric  disorders. 
It  follows  either  a  direct  irritation  of  the  nerves,  as  after  the  use  of 
rubber  dam  or  other  dental  operations  in  susceptible  persons,  or  may 
be  of  reflex  origin;  in  either  case  localized  peripheral  neuritis  being 
the  initial  lesion.^  There  is  some  reason  to  believe  that  infection 
plays  a  part  in  its  production.  As  a  preventive  it  is  well  to  lubricate 
the  lips  with  glycerin  and  rose  water  or  with  cold  cream  or  carbolated 
vaselin  1|  per  cent,  strength  (commercial)  when  much  stretching  or 
other  irritation  is  necessary. 

ECZEMA. 

A  pustular  form  of  eczema  or  a  seborrheic  form  may  occur  about 
the  border  of  the  lips.  The  cause  is  held  to  be  a  cutaneous  weakness 
due  to  various  constitutional  factors  with  local  excitation  by  irritants 
of  various  kinds,  no  bacterial  etiology  is  as  yet  assigned. 

HERPES  ZOSTER. 

This  is  a  probably  infectious  disease,  almost  invariably  mono- 
lateral,  associated  with  a  neuritis  usually  of  a  spinal  ganglion  or  with 
a  peripheral  neuritis,  which  produces,  first,  a  hyperesthesia  of  the 
integument,  macules,  and  later  vesicular  eruptions  not  usually 
beginning  on  a  mucous  surface.  They  appear  in  groups  and  may 
coalesce,  forming  patches.  Desiccation  forms  a  crust;  pus  may 
form. 

1  Oral  Diseases  and  Malformations. 

2  Hyde  and  MontgQiuery:    Diseases  of  the  Skin. 


736  INFECTIONS  OF  AND  FROM  THE  MOUTH 

The  interest  to  dentists  lies  in  the  fact  that  in  zester  of  the  head 
exfoliation  of  the  teeth  is  said  to  be  associated  in  rare  cases. ^ 

Some  have  considered  it  due  to  oral  sepsis.  Lain^  found  apical 
abscesses  in  95  per  cent,  of  his  cases. 

LEUKOPLAKIA  BUCCAnS.^ 

Upon  the  inner  surface  of  the  cheeks  or  lips,  and  upon  portions  of 
the  gum  and  the  dorsum  and  edges  of  the  tongue,  may  appear  sharply 
outlined,  dull,  whitish,  slate-colored  or  silver-whitish  points,  disks, 
streaks,  bands,  ribbons,  or  patches  of  irregular  shape,  either  flattened 
or  slightly  elevated,  above  the  general  level  of  the  mucous  surface. 
They  may  crack  or  fissure,  and  inflammation  of  the  derma  and  pain 
result.  Ordinarily  they  are  simply  rough  and  without  much  dis- 
comfort. It  occurs  almost  exclusively  in  males.  They  differ  from 
the  mucous  patches  of  syphilis  in  that  the  latter  are  soft  and  tend  to 
ulcerate,  and,  while  they  may  accompany  syphilis,  may  occur  in  its 
absence  or  of  any  history  of  it. 

They  simulate  the  keratosis  of  lichen  planus,  which  should,  however 
also  appear  as  papules  upon  other  parts  of  the  body. 

Apart  from  syphilis,  it  is  due  to  irritation  such  as  that  from 
tobacco  or  rough  teeth,  and  with  syphilis,  tobacco,  and  rough  teeth 
may  be  additional  excitants. 

R.  H.  Ivy  reports  three  cases  with  tendency  to  epitheliomatous 
degeneration,  all  without  history  of  syphilis,  and  in  two  of  which 
the  Wassermann  reaction  was  negative.^ 

The  use  of  alcohol  and  spices  are  also  a  cause. 

The  pellicle  is  closely  adherent,  and  consists  of  an  hypertrophied 
and  hyperkeratinized  epithelium,  with  more  or  less  inflammatory 
infiltration  of  the  derma  and  with  partial  obliteration  of  the  papillae. 

The  chief  danger  in  the  disease  is  the  tendency  to  epithelioma, 
some  authors  estimating  30  per  cent.,  especially  in  the  cases  in  which 
exfoliation  and  ulceration  occur.  Some  eighteen  years  ago  a  male 
patient  presented  with  a  leukoplakia  in  which  there  was  a  constant 
desquamation  as  though  very  hot  liquids  had  been  used.  Medical 
treatment  was  given,  tobacco  and  liquor  were  largely  avoided,  but 
after  about  twelve  years,  epithelioma  involving  a  jaw  operation 
occurred.  This  patient  was  apparently  cured,  but  the  epithelioma 
recurred  and  the  patient  recently  died  a  lingering  death. 

1  Hyde  and  Montgomery:  Diseases  of  the  Skin. 

^  Quoted  by  Nodine,  Dental  Cosmos,  November,  1917,  p.  1095, 

'Hyde  and  Montgomery:  Diseases  of  the  Skin. 

*  New  York  Medical  Journal,  October,  1912,  p.  1187, 


PHOSPHOR  NECROSIS  737 

The  use  of  soothing  mouth  washes,  together  with  a  hygienic  regimen 
and  the  avoidance  of  irritants  Hke  tobacco,  alcohol,  spiced,  hot,  or 
iced  foods.  The  correction  of  habit  and  institution  of  local  and  general 
hygiene  is  the  usual  treatment  to  avoid  epithelioma.  The  use  of 
caustics  has  been  objected  to  as  likely  to  cause  epithelioma  in  these 
cases.  Some  consider  that  it  is  very  infrequently  a  cause  of  epithe- 
lioma in  itself.  The  diagnosis  lies  clearly  within  the  province  of  the 
dentist  who  may  note  it  before  the  patient.  The  treatment  is 
usually  conducted  by  the  physician,  and  is  often  unsatisfactory  as 
to  permanent  cure.  Cases  with  syphilitic  history,  of  course,  require 
antisyphilitic  treatment. 

Leukoplakia  has  been  also  called  buccal  psoriasis,  but  psoriasis 
does  not  affect  mucous  surfaces,  hence  it  is  a  misnomer. 

UCHEN  PLANUS. 

This  condition,  which  may  simulate  leukoplakia,^  is  characterized 
by  an  eruption  consisting  of  glistening  flat-topped  polygonal  papules 
with  tendency  to  form  irregularly  arranged  groups.  On  the  mucous 
surface  they  appear  as  whitish  macules,  striae,  or  flat  papules  on  both 
sides  of  the  tongue  at  the  points  in  contact  with  the  molar  teeth. 

They  are  the  result  of  an  arterial  or  venous  hyperemia  of  the 
papillae  of  the  corium,  a  secondary  thickening  of  the  lower  part  of 
the  rete,  and  a  tertiary  flattening  of  the  papule  by  pressure. 

A  proliferation  of  cells  in  the  granular  layer  and  a  deposit  of 
keratohyalin  in  whitish  spots  occur.  This  causes  a  similarity  to 
leukoplakia.  It  usually  occurs  in  the  nervously  exhausted,  though 
many  patients  may  have  a  fair  degree  of  body  nutrition  while  yet 
nervously  exhausted. 

Lain  found  local  oral  infection  in  85  per  cent,  of  his  cases  (see  p.  736). 

PHOSPHOR  NECROSIS. 

This  disease  is  a  more  or  less  extensive  necrosis  of  the  maxillae  due 
to  the  entrance  of  phosphorus  or  its  fumes  into  contact  with  the 
periosteum  or  pericementum  of  a  tooth. 

It  was  formerly  frequent  in  match  factories,  when  white  phosphorus 
was  used,  though  now  less  when  the  red  is  employed,  but  has  occurred 
through  the  chewing  of  match  heads,  and  a  case  has  been  reported 
in  which  a  half  grain  taken  in  three  days  caused  it.^ 

As  it  does  not  ordinarily  occur  in  the  mouths  of  those  having 

1  New  York  Medical  Journal,  April  13,  1912. 
-  Arnone:    Dental  Cosmos,  1910,  p.  425. 

47 


738  INFECTIONS  OF  AND  FROM  THE  MOUTH 

sound  teeth,  it  is  generally  regarded  as  of  local  origin,  the  phosphorus 
gaining  entrance  either  through  the  pulp  canal  of  a  tooth,  or,  possibly, 
through  some  point  of  injury  external  to  the  tooth. 

Abscesses  containing  offensive  pus  cause  great  swelling  and  exces- 
sive salivation,  and  may  cause  several  fistulse,  while  the  swallowing 
of  the  discharge  causes  general  toxic  disturbance,  and  infection  such 
as  pneumonia  or  cerebrospinal  meningitis  may  have  rapid  effect. 

The  periosteum  remains  unaffected  as  to  its  vitality,  while  the 
bone  proper  undergoes  osteoporous  necrosis,  becoming  like  rotten 
sponge.  As  the  sequestrum  is  separated,  there  is  a  tendency  to 
formation  of  new  bone  by  the  periosteum.  The  necrosis  of  bone  may 
be  very  extensive,  involving  in  the  lower  jaw  the  entire  horizontal 
portion,  while  the  ramus  may  remain  unaffected.  In  the  lower  jaw, 
after  exfoliation,  the  bone  may  be  almost  entirely  restored  to  an 
amount  nearing  fair  comparison  with  the  ordinary  edentulous 
mouth,  while  in  the  upper  jaw  no  repair  occurs.  This  new  bone  may 
undergo  atrophy  if  not  put  to  work  by  artificial  teeth. ^  As  a  pro- 
phylactic sodium  bicarbonate  solutions  are  recommended  by  Arnone.^ 

SCORBUTUS. 

Scurvy  in  the  adult  is  a  disease  due  to  diet  and  in  former  days  was 
frequent  in  armies  and  among  sailors  on  long  voyages. 

The  use  of  a  restricted  diet  lacking  fresh  vegetables  and  fruits  was 
a  chief  cause.  It  is  supposed  to  be  due  to  lack  of  potassium  salts. 
Rhinehart^  classifies  the  following  s^nnptomatologj^ :  Slow  onset, 
swelling  about  eyes,  face  pale,  bloated,  mental  and  physical  debility, 
gums  spongy,  swollen  or  fungoid,  teeth  loose  or  may  drop  out,  occa- 
sional necrosis  of  jaw,  breath  offensive,  tongue  swoUen,  but  usually 
clean  and  pale,  appetite  lost  but  digestion  usually  good,  skin  dry  and 
muddy,  after  ten  days  capillary  hemorrhages  usually  about  hair 
follicles  of  legs.  Subnormal  temperature  or  fever,  heart  possibly 
feeble  or  palpitating.  Aside  from  oral  antisepsis  the  treatment  is  a 
general  reversal  of  diet,  giving  vegetables  rich  in  potassium  salts  and 
the  organic  acids  of  fruits  (see  page  739). 

PURPURA  HEMORRHAGICA. 

This  is  the  appearance  of  small  purplish  spots  beneath  the  skin 
and  mucous  membrane,  and  is  dependent  upon  infection  and  toxic 
conditions. 

1  For  consideration  of  treatment  the  reader  is  referred  to  Garretson's  System  of 
Oral  Surgery,  sixth  edition,  and  other  writings  upon  the  subject. 

2  Dental  Cosmos,  1909.-  ^  Ibid.,  1914,  p.  1217. 


ANGINA  739 

Brown/  following  Schamberg,  presents  the  following  clear  differ- 
ential symptoms: 

Scorbutus.  Purpur.a.  Hemorrhagica. 

1.  Occurs  in  those  subjects  due  to  lack  1.   No  such  etiological  relationship. 

of  vegetable  food  and  to  bad  hy- 
giene. 

2.  Definite  antecedent  symptoms,  weak-  2.  Antecedent  signs  slight  or  absent. 

ness,  impaired  circulation,  etc. 

3.  Onset  slow.  3.  Onset  sudden. 

4.  Gums  spongy,  swollen,  and  bleeding;  4.  Gums  often  bleeding,  but  not  swollen. 

teeth  loose. 

5.  Severe  muscular  pain,  5.   Less  marked. 

6.  Brawny  infiltration  of  lower  extremi-  6.  Not  present. 

ties. 

7.  Hemorrhages     from     mucous     mem-  7.  Hemorrhages    from    mucous    mem- 

branes, not  profuse,  as  a  rule.  branes  so  severe  as  to  sometimes 

prove  fatal. 

LEPROSY. 

During  the  progress  of  leprosy,  an  infective  disease,  characteristic 
nodules  and  ulcers  appear  about  the  oral  structures.  As  many  parts 
of  the  head  are  affected  in  like  manner,  these  are  but  symptoms  of 
the  progress  of  the  effects  of  the  Bacillus  lepra.- 


ANGINA. 

Angina  is  usually  defined  as  a  sense  of  choking  or  suffocation, 
a  symptom  which  accompanies  inflammatory  affections  of  the 
pharynx  as  well  as  the  paroxysmal  neuralgic  affection  of  the  heart 
known  as  angina  pectoris. 

Angina  Simplex. — This  is  inflammation  of  the  pharynx,  with,  of 
course,  more  or  less  swelling  and  infiltration. of  exudate.  Swallowing 
may  be  difficult.  Local  depletion  and  sedative  washes,  with  general 
derivation,  are  indicated.  If  clu-onic,  stimulant  washes  are  useful 
combined  with  general  tonic  treatment. 

Ludwig's  Angina. — In  1836  Lud-^^g  described  a  disease  which  is 
considered  to  be  an  infectious  cellulitis  in  the  submaxillary  region, 
which  may  extend  deeply  into  the  tissues  of  the  neck.  The  infection 
is  thought  to  be  due  to  the  Streptococcus  pyogenes  or  bacillus  of 
malignant  edema,  though  the  Staphylococci  and  Pneumococcus  are 
found,  and  probably  enter  the  cellular  tissue  of  the  submaxillary 
region  and  neck  through  the  oral  or  pharyngeal  mucous  membrane 
or  a  wound.  An  apical  abscess,  also,  the  repeated  impaction  of  food 
into  the  pericoronal  region,  especially  about  a  third  molar,  and  its 

J  Dental  Cosmos,  1911,  p.  296. 

2  por  an  exhaustive  article  see  Oliver,  Dental  Cosmos,  1908, 


740 


INFECTIONS  OF  AND  FROM  THE  MOUTH 


fermentation  have  caused  a  deep  infection  resulting  in  this  disease. 
The  patient  has  lassitude,  chilliness,  and  fever. 

A  hard  swelling  appears  beneath  the  mandible  after  several  days, 
and  extends  toward  the  neck  and  under  the  tongue.  There  is  mus- 
cular rigidity  and  the  head  is  inclined  in  one  direction.  The  skin  is 
not  much  reddened. 

Later  edema  is  marked  and  may  extend  upward  toward  the 
parotid  gland  or  the  glottis.  Breathing  and  swallowing  are  rendered 
diflScult  by  oral  and  pharyngeal  swellings.  There  are  the  usual  oral 
symptoms  of  inflammation.  Upon  incision  the  connective  tissues 
are  found  to  be  sloughing,  grayish  black  in  color,  and  may  ooze  pus. 

The  board-like  hardness  of  the  floor  of  the  mouth  and  the  marked 
dyspnea  are  constant  features. 

The  spread  of  the  infection  being  by  continuity  of  cellular  spaces, 
the  glands  are  much  enlarged. 

A  large  abscess  may  form  and  discharge.  Pneumonia,  septicemia, 
and  pyemia  are  complications  to  be  feared  as  the  result  of  spreading 
infection.  Incisions  for  drainage  and  antisepsis  are  usually  con- 
joined with  systemic  treatment,  but  as  the  case  is  often  of  dental 
origin  the  cause  should  be  removed. 


Fig.  693 

'  '  ■■'^ 

Spirochetes  of  Vincent's  angina.     (M.  T.  Barrett.) 


Vincent's  Angina. — This  is  an  edematous  tonsillitis,  which  may 
affect  also  the  mucous  membrane  of  the  mouth  and  pharynx,  fol- 
lowed by  the  formation  of  a  pseudomembrane  as  in  diphtheria,  later 
ulceration  and  hemorrhage  may  appear.  There  are  the  usual  accom- 
paniments of  inflammation  in  this  locality,  together  with  fever  and 
sometimes  rigors.  It  usually  lasts  about  two  weeks.  It  also  occurs 
about  the  gums  without  necessarily  affecting  the  pharynx,  and  here 
maj^  last  much  longer.  Here  it  produces  a  dirty  ulceration  of  the 
gum  margins  producing  a  foul  odor  (see  page  608). 


INFECTIONS  FROM  THE  MOUTH  741 

The  differential  diagnosis  from  diphtheria  and  syphihs  is  made  by 
microscopic  examination.  The  Bacillus  fusiformis,  spindle-shaped, 
pointed  at  extremities,  and  6  to  10/x  in  length,  is  usually  associated 
with  a  long  thin  spirillum.     (See  Figs.  580  and  693.) 

They  take  several  stains,  but  not  the  Gram.  In  diphtheria, 
Loeffler's  bacilli,  and  in  syphilis  the  treponema  pallidum  would  be 
found.  Tuberculosis,  gonorrhea,  stomatitis,  and  pyorrhea  must 
also  be  differentiated.     (Lederer.) 

In  the  treatment  mercuric  chlorid  1  to  10,000  in  4  per  cent,  boric 
acid  solution,  and  especially  salvarsan,  10  per  cent,  in  sesame  oil, 
suspended  by  the  aid  of  lodipin  (Merck)  is  recommended  for  injec- 
tion into  the  pockets  or  applied  to  the  gum,  are  highly  recommended 
by  Lederer.  The  writer  has  cured  a  number  of  cases  of  this  type 
by  the  use  of  mercuric  chlorid,  1  grain  in  each  four  ounces  of  H2O2. 
A  microscopic  examination  was  not  made.^  Vaughan  recommends 
silver  nitrate,  4  to  8  per  cent.,  Lugol's  solution,  chromic  acid,  10  per 
cent.,  zinc  chlorid,  2  per  cent.,  and  Argyrol  full  strength,  also  a  light 
diet  and  cathartics.     (Other  treatments  on  page  61 5)  .^ 

INFECTIONS  FROM  THE  MOUTH. 

General  Septic  Diseases  of  Dental  Origin. — ^The  effect  of  the  exist- 
ence of  dental  diseases  upon  the  body  at  large,  particularly  as  regards 
secondary  infection,  is  a  matter  increasing  in  importance  as  the  possi- 
bilities of  their  connection  are  made  out.  At  present  the  organisms 
of  greatest  demonstrable  pathological  interest  are  the  streptococci 
and  pyogenic  cocci.  The  almost  constant  presence  of  these  organisms 
in  the  mouth,  carried  thence  into  the  pharynx,  posterior  nares,  larynx, 
lungs,  and  stomachy  furnishes  the  reason  for  the  pyogenic  and  phleg- 
monous inflammations  which  occur  in  these  organs.  The  diplococcus 
of  pnemnonia,  a  frequent  organism,  but  waits  a  favorable  opportunity 
to  establish  high  inflammations  and  fibrinous  exudations  in  the  lungs, 
and  possibly  in  other  structures.  The  oral  pneumococcus  is  now 
rather  regarded  as  not  the  one  producing  pneumonia. 

The  most  important  clinical  associations  of  dental  with  general 
infections  are  diseases  of  the  pericementum,  but  the  pulps  of  teeth 
are  claimed  by  Price^  to  take  up  and  transmit  the  products  of  the 
action  of  septic  organisms.  It  must  be  remembered  that  the  veins 
may  transmit  the  poison,  and,  in  addition,  may  perhaps  convey 

1  For  an  exhaustive  article  see  Vaughan,  Dental  Cosmos,  June,  1912. 

2  For  beautiftil  illustrations  of  many  of  these  oral  conditions.  See  Brown's  Oral 
Diseases  and  Malformations. 

3  Lecture  before  the  Pennsylvania  State  Dental  Society,  1917. 


742  INFECTIONS  OF  AND  FROM  THE  MOUTH 

organisms  from  a  diseased  but  still  vital  pulp  to  distant  parts.  When, 
however,  the  pulp  is  dead  and  the  pericementum  is  invaded,  there  is 
no  doubt  of  general  infection  from  this  local  source.  More  or  less 
septic  intoxication  is  a  common  attendant  upon  severe  septic  apical 
pericementitis,  and  septicemia  accompanied  by  inflammation  of  the 
neighboring  lymphatic  glands  is  of  sufficient  frequency  to  emphasize 
the  need  of  the  vigorous  antiseptic  treatment  recommended  in  all  of 
these  cases. 

Pyemia  is  far  more  uncommon.^  Pyogenic  organisms,  gaining 
access  to  the  blood  current  from  the  local  source  of  infection,  establish 
suppuration  in  distant  parts;  in  other  parts  of  the  bone,  or  in  other 
bones  (osteomyelitis),  in  the  lungs,  meninges,  and  substance  of  the 
brain.  One  case^  has  been  reported  where  abscess  of  a  toe,  ear,  and 
forearm  ceased,  and  recovery  took  place  after  treatment  and  filling 
of  septic  root  canals.  Several  cases  are  tabulated  by  the  same  author 
in  which  extensive  necrosis  and  death  resulted  from  pyemic  infec- 
tion from  septic  pericementitis.  Some  of  these  cases  recorded  were 
associated  with  acute,  some  with  chronic,  septic  pericementitis. 

In  addition  to  the  usual  pyogenic  cocci.  Miller  has  isolated  several 
forms  of  cocci,  bacilli,  and  spirilla,  forming  products  which,  if  injected 
into  the  circulation  of  animals,  cause  death  from  septicemia  in  from 
hours  to  days.  As  many  of  these  forms  may  be  brought  into  rela- 
tion with  deep  parts  by  the  anatomical  conditions  created  by  pulp 
death,  the  possibilities  of  many  types  of  infection  via  pulpless  teeth 
are  evident.     (See  pages  532  and  557.) 

The  possibilities  of  local  as  well  as  general  infections  through  the 
conditions  established  in  the  several  forms  of  pyorrhea  alveolaris 
should  not  be  forgotten.     (See  page  696.) 

The  pockets  formed  by  the  soft  tissues  overhanging  lower  third 
molars  whose  eruption  is  impeded  invite  the  passage  of  septic  organ- 
isms to  deep  parts.  Local  pyogenic  infections  are  common  in  these 
cases,  and  may  extend  into  the  pharynx  and  the  submaxillary  tissues, 
as  in  Ludwig's  angina. 

The  question  is  one  of  systemic  infection  from  a  dental  focus  of 
infection;  in  addition  the  mouth  being  a  port  of  entry  for  many 
bacteria,  the  diseases  they  produce  may  in  a  general  way  be  considered 
as  having  origin  in  the  mouth,  but  in  a  specific  way  only  such 
diseases  as  aheady  exist  in  the  mouth  and  possibly  producing 
systemic  disease  are  here  considered. 

Rheumatism.— This  is  an  inflammatory  disease  now  generally 
regarded  as  due  to  bacteria  carried  by  the  blood  to  the  diseased  tissue 

1  MUler:    Dental  Cosmos,  1891.  *  Ibid. 


INFECTIONS  FROM  THE  MOUTH  743 

from  some  primary  som-ce  (focus),  of  infection,  e.  //.,  the  urethra 
(gonococci)  the  tonsils,  the  mouth  (pyorrhea  pockets  and  apical 
granulomata,  etc.),  or  possibly  from  other  infectious  conditions. 

The  forms  vary  from  muscular  inflammation  of  which  wry-neck 
is  one  form  to  inflammation  of  the  synovial  membranes  of  joints  and 
later  of  the  cartilages  which  may,  if  infected  by  pyogenic  bacteria, 
even  be  purulent.  Arthritis  deformans  is  a  chronic  inflammation  of 
similar  origin  resulting  in  destruction  and  construction  changes  in 
the  bones,  producing  flexed  finger,  spinal  curves,  etc.  Viewing  the 
disease  in  its  entirety  it  would  seem  that  the  simple  forms  are  due  to 
Streptococcus  viridans,  organisms  of  low  virulence  producing  non- 
suppm-ative  inflammations  and  often  originating  from  focal  infection 
in  the  mouth.  The  more  suppurative  forms  are  probably  due  to 
pyogenic  organisms  having  origin  in  pus  foci  in  the  mouth,  tonsils  or 
other  locations.  There  is  necessarily  pain  and  loss  of  function  and 
often  the  other  symptoms  of  acute  inflammation  and  when  established 
may  continue  in  spite  of  removal  of  a  primary  focus,  i.  e.,  they  act 
as  foci  in  themselves.  However,  many  cases  subside  upon  the  removal 
of  the  primary  focus,  and  an  autogenous  vaccine  may  be  an  aid  to 
recovery. 

Endocarditis. — ^An  infective  inflammation  nearly  always  of  the 
valves  of  the  heart,  usuaUy  the  mitral  and  aortic.  It  follows  rheu- 
matism in  any  form,  also  often  pneumonia  and  may  f oUow  any  of  the 
principal  infective  diseases.  Staphylococci,  gonococci  and  strepto- 
cocci even  the  Streptococcus  viridans  so  commonly  found  in  dental 
granuloma,  tonsils,  etc.,  may  act  as  the  infecting  organism.  The 
bacteria,  either  in  the  blood  stream,  passing  through  the  heart  valves 
or  more  probably  entering  their  capillary  circulation,  produce  epi- 
thelial vegetations  which  may  later  be  carried  off  as  emboli  with 
dangers  of  embolism.  If  the  emboli  are  infective  metastatic  infec- 
tions are  possible  (as  infective  infarctions,  etc.).  Infectious  infarc- 
tions often  appear  in  the  end  arteries  of  the  kidney  and  may  lead  to 
abscess.  They  are  usually  the  result  of  malignant  endocarditis 
(pyogenic  bacteria) . 

When  chronic,  valvular  incompetency  with  regurgitation  is  pro- 
duced by  prevention  of  apposition  of  the  edges  of  the  valves  by  the 
excrescences.  HA-pertrophy  of  the  heart  is  a  result  of  the  effort  at 
compensation  for  mitral  regurgitation  and  its  consequent  effect  upon 
blood  impulse.  ^McFarland  states  that  a  safe  balance  is  found  in 
combined  hjT)ertrophy  of  the  left  ventricle,  dilatation  of  the  left 
auricle,  passive  congestion  of  the  lungs  and  h}-pertrophy  of  the  right 
ventricle  which  may  later  be  dangerously  upset  by  insufficency  in  the 
tricuspid  valve  (right  ventricle). 


744  INFECTIONS  OF  AND  FROM  THE  MOUTH 

Fibroid  induration,  degenerations  and  calcifications  are  the  com- 
mon sequelse.  Appropriate  murmurs  and  pulse  signs  are  noted  with 
the  various  conditions  established.  (See  INIcFarland's  and  other 
Text-books  on  Pathology.) 

Neuritis. — ^This  is  an  inflammation  of  nerve  tissue  either  due  to 
traiuna  or  to  focal  infection.  The  inflammation  may  be  acute  with 
its  phenomena  (occasionally  suppuration)  or  chronic  with  degenera- 
tive changes  in  the  nerve  tissue.  If  the  tissue  controls  important 
parts  secondary  effects  may  arise. 

As  related  to  dentistry  it  is  one  of  the  consequences  of  oral  infections, 
its  etiology  and  pathology  being  sunilar  to  that  of  rheumatism,  i.  e., 
infection  derived  from  the  teeth  or  gum  pockets  is  absorbed  and  causes 
nerve  inflammation  rather  than  joint  affection. 

Jiymphadenitis. — ^This  is  an  inflammation  of  the  lymph  nodes, 
usually  occurring  in  infections  in  the  nearest  nodes  through  which  the 
infected  lymph  drains.  Swelling  of  the  smaller  nodes  should  lead  to 
examination  of  the  part  from  which  they  drain. 

Lymphangitis  is  inflammation  of  the  lymphatic  vessels  due  prob- 
ably to  infective  or  at  least  toxic  product  from  a  focus.  Thus  in  a 
felon,  a  bright  red  streak  may  run  from  the  hand  to  the  axilla,  follow- 
ing the  line  of  the  vessel.  Occasionally  chronic  lymphatic  engorge- 
ment leads  to  dilatation  with  possible  proliferation  of  the  surrounding 
connective  tissue.     (Ljinphangiectasis.) 

Furunculosis. — ^The  presence  of  multiple  abscesses  (boils,  car- 
buncles, etc.)  in  the  skin  may  be  due  to  direct  infection  by  bacteria, 
always  more  or  less  present  upon  the  skin  probably  with  plugging  of  a 
fat  duct  or  entrance  into  a  hair  follicle,  but  a  lowered  resistance  to 
infection  and  a  possible  skin  infection  by  carriage  through  the  blood 
of  bacteria  from  sohie  focal  infection  as  about  the  teeth,  tonsils,  etc., 
is  quite  possible.  Schamberg^  coincides  mth  this  view.  Grie^'es  lists 
this  latter  as  a  cause  (see  page  557). 

Nephritis. — ^Viewed  as  an  infective  condition  nephritis  or  inflam- 
mation of  the  kidney  is  probably  due  to  the  toxins  derived  from 
general  infections  (e.  g.,  yellow  fever)  or  the  bacteria  from  some 
focal  infection  (possibly  about  teeth) . 

The  damage  is  to  the  excretory  portions,  glomerules  and  tubes, 
the  function  of  which  is  to  excrete  the  irritatmg  substances  coming  to 
them.  If  these  subside  as  in  yellow  fever  the  symptoms  (albuminuria) 
disappear  and  probably  little  injury  is  done.  If  contmued  a  long 
time  as  in  uricacidosis  or  other  leukomain  production,  alcoholism, 
etc.,  the  parenchyma  degenerates  (fatty)  and  the  connective  tissue 

1  Private  Communication. 


INFECTIONS  FROM  THE  MOUTH  745 

increases.  McFarland  describes  it  as  "characterized  by  increased 
quantity  of  urine  of  low  specific  gravity,  little  or  no  albumin  and  very 
few  tube  casts  of  which  the  hyalin,  pale  granular  and  waxy  varieties 
only  are  found."  Stengel  remarks  the  presence  of  streptococci  in 
cases  of  obscure  infectious  origin  which  is  confirmatory  of  recent 
observations  regarding  the  focal  infections  about  teeth  as  a  cause. 
In  fact,  Hartzell  and  Henrici  have  experimentally  produced  nephritis 
in  animals  by  injecting  oral  streptococci  into  their  blood.    (See  p.  560.) 

Infectious  infarction  of  the  kidney  is  usually  produced  by  emboli 
from  suppurative  endocarditis  and  leads  to  abscess  in  the  kidney 
(McFarland).  In  kidney  lesions  due  to  oral  infections,  Hartzelli 
notes  albuminuria  and  casts  in  quantity,  lessening  as  the  local  foci 
of  pus  formation  are  removed. 

Alimentary  Canal  Infections. — From  the  teeth  down  there  is 
no  difficulty  in  understanding  tonsillitis,  gastritis,  gastro-enteritis, 
enteritis,  cholecystitis,  colitis,  appendicitis  and  proctitis  as  septic 
mflammations  due  to  oral  bacteria  entering  the  alimentary  canal. 
Of  course  they  need  not  be  due  to  teeth  in  all  cases,  but  pyorrhea, 
chronic  abscesses  and  nasal  and  tonsillar  suppurations  are  easily  a 
possible  cause.  It  is  curious  how  convinced  people  may  be  as  to  the 
effects  of  disease  of  the  stomach  upon  teeth,  e.  g.,  as  a  cause  of  caries 
or  pyorrhea,  while  skeptical  of  oral  disease  as  a  cause  of  the  stomach 
disease,  etc. ;  no  matter  how  carefully  explained.  This  is  due  to  long 
continued  custom  of  thought. 

McFarland  states  that  bacteria,  unusual  to  the  intestines  having 
marked  infectious  powers,  such  as  streptococcus,  typhoid  bacillus, 
B.  dysenterise,  cholera  spirillum,  tubercle  bacillus,  and  also  ameba 
coli  and  ameba  hystolitica  of  dysentery,  may  occasion  extensive 
and  characteristic  lesions.  The  enteritis  may  be  catarrhal,  follicular, 
pseudomembranous,  or  ulcerative.  Appendicitis  has  the  intestine 
as  its  source  of  infection  and  mechanical  irritations  which,  as  shown, 
may  originally  be  in  the  mouth.  Bilious  attacks  have  been  due  to 
teeth. 

The  reverse  order  of  disease  is  always  possible  in  that  alimentary 
canal  disturbances  affect  physiological  digestion  and  absorption  as 
well  as  produce  abnormal  fermentative  products  which  are  absorbed. 
Thus  cell  nutrition  is  disturbed  by  lack  of  proper  food  supply  and  by 
toxic  substances  in  the  blood  stream  which  also  may  introduce  the 
element  of  retained  leukomains  due  to  improper  elimination  at  the 
kidney,  skin,  liver,  lungs,  etc.  The  whole  range  of  maLnutritional 
disorders  is  involved  which  necessarily  affects  systemic  resistance  to 

1  Journal  of  Allied  Sccieties,  June,  1914. 


746  INFECTIONS  OF  AND  FROM  THE  MOUTH 

bacteria  and  local  resistance  as  well.  This  is  a  vicious  circle.  (See 
also  Headache.)  Babcock^  stated  that  in  all  cases  of  cancer  of  the 
stomach  his  patients  had  pyorrhea.  This  could  be  a  direct  chronic 
cause  of  irritation  from  the  mouth  or  it  might  be  argued  to  begin 
with  the  cancer  as  a  vicious  circle. 

Iritis. — ^Inflammation  of  the  iris  has  occasionally  been  connected 
with  oral  infection  as  shown  by  its  cure  as  the  oral  infection  is  removed 
(see  page  557.) 

Headaches. — These  are  often  due  to  alimentary  disturbances, 
often  the  result  of  infectious  fermentations.  The  alimentary  canal 
is  a  port  of  entry  to  the  blood. 

Crofton^  states  that : 

1.  Microbes  constantly  pass  through  the  wall  of  the  alimentary 
canal  into  the  radicals  of  the  portal  veins  and  lymphatics  being  con- 
veyed by  leukocytes. 

2.  That  if  normal  resistance  of  the  mucous  membrane  is  lowered, 
microbes  ordinarily  harmless  may  become  pathogenic  and  then 
produce  a  general  infection. 

3.  That  swallowed  pathogenic  bacteria  may  lower  the  resistance 
of  the  mucous  membrane. 

4.  That  the  stomach  may  be  invaded  from  the  intestine. 

5.  That  B.  coli  communis,  streptococci  and  anaerobic  bacteria  are 
so  constantly  present  as  often  to  be  considered  normal. 

Since  headache  is  known  to  have  such  an  origin  in  many  cases,  it 
is  reasonable  to  suppose  that  persistently  recurrent  headaches  may  be 
due  to  oral  foci  of  infection  and  have  indeed  disappeared  on  removal 
of  such  foci.  In  one  case  after  a  single  treatment  of  an  abscess  on  a 
lower  cuspid,  headache  of  constant  character  disappeared,  (see  pages 
123  and  557). 

Nervous  Disorders. — Cases  of  melancholia,  or  occasional  delusions, 
as  of  approaching  msanity,  may  be  caused  by  focal  infection.  In  one 
peculiar  case  a  patient  was  unable  to  swallow,  and  the  extraction  of 
two  abscessed  teeth  and  one  markedly  pyorrhetic  tooth,  together  with 
the  clearing  up  of  a  reasonable  general  pyorrhea,  rapidly  cured  the 
dysphagia.    Nervous  breakdown  is  an  occasional  symptom. 

1  Private  CommuDication. 

2  Therapeutic  Immunization,  p.  71. 


CHAPTER   XXV. 
PROPHYLAXIS. 

By  prophylaxis  is  meant  the  prevention  of  disease  and  as  a  broad 
conception  inchides  any  measures  whatsoever  the  application  of  which 
will  prevent  the  occurrence  or  recurrence  of  disease  in  general.  As 
applied  to  a  particular  disease  the  measures  employed  are  spoken  of 
as  the  prophylaxis  of  that  disease,  e.  g  ,  prophylaxis  of  dental  caries, 
tuberculosis,  etc.  By  common  consent  the  periodic  application  of 
such  treatment  as  is  necessary  to  prevent  the  occiu-rence  of  disease 
is  called  prophylactic  treatment. 

In  dentistry  prophylaxis  involves  first  the  removal  of  the  cause  or 
causing  factors  leading  to: 

1.  Dental  caries  which  leads  eventually  to  pulp  diseases  and  their 
consequences. 

2.  Gingivitis  and  pyorrhea  alveolaris  (periodontoclasia)  and  such 
systemic  conditions  as  are  consequent  upon  them. 

3.  (a)  General  malocclusion  of  the  teeth,  (b)  malocclusion  due  to 
loss  of  necessary  occluding  teeth  or  individual  malocclusions  both 
involving  overwork  of  the  pericementum  leading  to  its  degeneration. 

4.  The  effects  of  diet  or  water  taken  by  the  mother  or  the  child, 
or  disease  of  either  having  influence  upon  either  the  first  or  second 
dentition. 

5.  The  effects  of  systemic  or  general  oral  acidity  or  wear. 

6.  A  sixth  classification  involves  the  discovery  and  removal  of  all 
local  foci  of  infection  which  may  be  consequent  upon  dental  caries 
or  pulp  disease  or  pyorrhea  alveolaris  as  a  means  of  prevention  of 
systemic  infection  expressing  itself,  as  a  rule,  in  arthritis,  muscular 
rheumatism,  endocarditis,  abscesses  in  distant  localities,  etc.  (see 
pages  557  and  743. 

There  can  be  at  the  present  time  no  doubt  that  the  only  correct 
view  of  dental  prophylaxis  is  to  regard  the  mouth  in  its  entirety  as  a 
possible  source  of  infection  which  may  overwhelm  the  entire  system. 
This  includes  two  views: 

1.  That  the  infection  actually  exists  in  one  or  more  of  the  follow- 
ing conditions: 

(a)  Cavities  of  decay  or  other  foci  of  dental  caries  acting  as  centers 
of  infection  for  the  mouth  and  alimentary  canal. 

(747) 


748  PROPHYLAXIS 

(b)  Gingi^'al  infections,  as  in  gingivitis  or  pyorrhea  alveolaris, 
also  acting  as  foci  of  infection  for  mouth  and  aUmentary  canal  and 
by  way  of  the  blood. 

(c)  Apical  abscesses,  acute  or  chronic  (including  granulomas),  or 
even  infected  living  or  putrescent  pulps,  which  do  not  show,  radio- 
graphically,  abscesses  in  connection  with  them,  all  of  which  may  act 
by  way  of  the  blood  stream  or  when  connected  with  the  mouth  act 
by  that  channel. 

(d)  Sepsis  about  bridges,  plates,  etc.,  infecting  the  alimentary  canal, 
2.  That  the  mouth  is  an  infected  locality  and  that  at  any  time 

caries  or  gmgivitis  may  begin  unless  prophylactic  treatment  is  insti- 
tuted and  if  neglected  lead  to  the  foregomg  local  conditions  and  so  to 
systemic  infections. 

As  with  the  exceptions  of  Class  4  and  general  orthodontic  mal- 
occlusion in  Class  3,  and  pulp  diseases  due  to  accidents  such  as  blows, 
etc.,  and  erosion  and  abrasion  all  dental  diseases  are  probably  due 
to  microbic  plaques  upon  the  teeth  (see  page  244) ;  it  follows  that  the 
systematic  removal  of  such  plaques  and  their  associate  factors  consti- 
tutes the  rational  prophylactic  treatment  for  prophylaxis  of  the  said 
diseases.  Clinical  experience  has  amply  demonstrated  that  a  thor- 
ough prophylactic  treatment  at  periods  varying  from  one  to  three 
months  will  prevent  the  inception  of  caries  and  gingivitis  if  the 
patient  gives  intelligent  assistance.  In  case  of  very  active  pyorrhea, 
when  the  conformation  of  necks  of  teeth  are  such  as  to  render  per- 
sonal attention  practically  impossible,  more  frequent  attention  by  the 
dentist  has  at  times  been  necessary  and  appreciated  by  the  patient. 

As  patients  usually  present  with  some  form  of  dental  disease,  the 
first  step  after  treating  the  acute  condition  is  to  place  the  mouth 
in  as  cleanly  a  state  as  possible  and  to  obliterate  any  gmn  disease, 
while  at  the  same  time  cavities  of  decay  are  to  be  prepared  and  filled 
as  rapidly  as  conveniently  possible  wdth  exactly  adapted,  perfectly 
contoured,  highly  polished,  insoluble  (insofar  as  utilizable)  fillings, 
the  margins  of  which  are  extended  into  areas  subjected  to  friction  by 
ordinary  forces,  such  as  food  excursions,  brushing,  etc.  Departures 
from  this  principle  are  to  be  made  for  well-judged  reasons  only  and 
when  made  prophylaxis  must  be  more  vigorous.  There  can  be  no 
question  that  as  to  the  choice  between  small  unextended  approximal 
fillings  plus  prophylaxis  and  waiting  for  cavities  to  become  larger  so 
that  contoured  fillings  may  be  inserted  the  preference  lies  with  the 
former,  as  in  the  latter  method  lies  the  danger  of  pulp  approach  and 
death  in  various  ways  thus  inviting  the  condition  so  frequently  seen 
of  the  presence  of  several  treated  or  untreated  devitalized  teeth  in  a 
mouth  with  its  dangers  from  systemic  disease  (see  page  557).    There 


PROPHYLAXIS  749 

is,  of  course,  the  middle  ground  of  extension  of  all  cavities,  however 
small,  to  which,  however,  there  are  many  objections,  though  argu- 
ments pro  and  con  are  valid. 

In  all  operations  the  conditions  of  recurrence  must  be  considered 
and  if  possible  avoided  (see  page  357). 

Granting  the  necessity  for  attention  to  actual  conditions  in  order 
that  prophylaxis  may  be  effectual  a  first  step  is  the  diagnosis  of  the 
extent  to  which  the  patient  has  departed  from  oral  cleanliness  and 
the  demonstration  of  the  same  to  the  patient.  The  disease  existing 
may  be  demonstrated  first,  then  the  presence  of  the  causati"\'e  factors 
in  the  microbic  plaque,  food  collection  and  calculus. 

The  microbic  plaques  are  readily  shown  by  means  of  iodin,  either  in 
the  form  of  the  tincture  or  a  solution  of  the  same  in  alcohol  or  water, 
or  pure  or  diluted  iodoglycerol,  or  in  a  special  disclosing  iodin  solu- 
tion.^ The  introduction  of  this  means  of  disclosure  is  attributed 
to  the  late  Dr.  Francis-  of  New  York,  who  about  1884  remarked  that 
"it  does  not  so  much  remove  the  soft  collections  on  the  teeth  as  dis- 
closes their  location."  The  iodin  imparts  its  brownish  color  to  both 
clean  and  plaqued  surfaces  and  can  be  douched  oif  the  clean  portion 
by  means  of  water  leaving  the  plaques  stained  (Fig.  261).  The  figure 
whUe  of  caries,  so  closely  illustrates  that  it  may  serve  instead  of  a 
special  illustration.  At  this  demonstration  the  value  of  brush  and 
floss  motions  can  be  sho^\Ti  to  the  patient  and  is  very  convincing. 
That  these  collections  have  been  denied  to  be  plaques  is  kno\\m  to  the 
■v^T-iter  and  that  they  are  often  found  where  no  caries  exists  involves 
a  consideration  of  their  bacterial  content  (whether  caries  fmigi  or 
not).  The  fact  that  they  are  found  as  causes  of  gingivitis,  etc.,  in 
which  caries  is  not  present  and  that  also  their  removal  cures  the  dis- 
ease is  again  evidence  of  a  varied  bacterial  content.  In  either  case 
the  question  of  the  carbohydrate  food  factor  as  in  caries  or  the 
albumin  factor  (gum  secretion)  as  in  gingivitis  is  also  to  be  considered 
in  the  pathogenesis  of  the  respective  diseases.  These  questions  are 
stiU  unsolved  in  their  entirety  though  partially  understood.  The 
cleaning  of  the  teeth  by  means  of  scalers,  brush  wheels  or  rubber  cups 
charged  with  pumice  and  with  flat  floss  charged  mth  pumice  is  a 

1  F.  H.  Skinner  offers  the  following  disclosing  solution: 

IJ — Iodin  crystals .      -      .      .50  grs. 

Potassium  iodid 15  grs. 

Zinc  iodid •    ....      15  grs. 

Glycerin 4  drs. 

Distilled  water 4  drs. 

Mix. — Put  up  in  a  glass-stoppered  bottle. 

Sig. — Paint  two  or  three  teeth  at  a  time.     Rinse  immediately  with  water. 

2  Lecture  at  the  Philadelphia  Dental  College. 


750  PROPHYLAXIS 

routine  method  (see  stains  and  calculus)  of  clearing  the  teeth  of  gross 
accumulations.  At  stated  intervals  judged  by  actual  experience 
with  the  indi\ddual  patient  appointments  are  made  at  which  any 
collections  escaping  the  self-ministrations  of  the  patient  are  to  be 
removed.  There  can  be  no  reasonable  objection  to  the  use  of  a  soft 
rubber  cup  and  oxide  of  tin  or  precipitated  chalk  upon  the  labial  and 
lingual  surfaces  at  this  sitting.  Following  this  the  teeth  are  to  be 
stained  and  with  a  wedge-shaped  orangewood  point  and  the  suit- 
able abrasive,  pumice,  XXX  silex,  chalk,  etc.,  each  tooth  cervix 
is  polished  clean  in  so  far  as  the  stick  will  do  it.  The  use  of  the 
wood  point  has  been  much  dilated  upon  and  its  importance  exagger- 
ated to  the  point  of  abuse  causing  gum  recession,  abrasion,  etc. 
In  practice  gentle  manipulation  calculated  simply  to  remove  the 
plaques  is? all  that  is  necessary  or  desirable.  It  is  true  that  it  is 
better  to  slightly  overdo  the  work  than  not  to  accomplish  the  object 
sought.  All  that  is  rational  to  expect  is  the  cleansing  of  the  buccal 
and  lingual  surfaces  and  the  surfaces  at  the  embrasures.  An  angle 
cured  of  pyorrhetic  conditions  should  have  especial  attention.  The 
flat  floss  will  accomplish  the  balance  of  the  work. 

The  Skiimer  or  Jack  porte  polisher  (Fig.  619)  are  useful.  They  are 
held  with  the  pen  grasp,  the  third  and  fourth  fingers  being  used  as  a 
fulcrum  while  the  application  is  made  by  a  semi-rotary  movement  of 
the  wrist  or  forearm,  or  held  with  the  palm  grasp,  the  thumb  being 
used  as  a  fulcrum. 

Next  flat  floss  is  passed  between  the  teeth  and  gently  mider  the 
gmn  margin  then  bent  around  the  neck  as  far  as  possible  and  drawn 
back  and  forth  and  out  over  the  contact  point.  It  is  reintroduced 
at  the  same  space  and  the  operation  repeated  on  the  adjoining  tooth. 
The  teeth  are  to  be  reexamined  for  any  cavities  that  may  have  reached 
a  stage  requiring  filling,  a  possibility  due  to  the  difficulty  of  diagnosis 
at  the  previous  sittings  (see  page  301).  These  cavity  appearances  are 
fewer  and  fewer  as  the  sittings  continue  with  regularity.  Silver 
nitrate,  40  per  cent.,  may  be  applied  to  any  surfaces  likely  to  decay 
as  sulci  or  contact  points  or  in  very  superficial  decalcification  of 
tooth  cervices  the  saturated  solution  may  be  applied,  the  black  stain 
resulting  acting  in  some  degree  as  a  deterrent  of  further  action. 

In  teeth  not  yet  fully  erupted  white  or  black  copper  cement  or 
silver  cement  may  be  wiped  into  the  sulci  to  prevent  decay  w^hile  they 
erupt  to  full  occlusion. 

Any  gingival  irritation  is  noted  and  if  necessary  treated.  The 
patient  is  cautioned  as  to  having  avoided  certain  points  in  self  pro- 
phylaxis which  is  an  all-important  adjunct  as  plaques  and  carbo- 
hydrate foods  are  quickly  collected  (see  page  258), 


SELF  PROPHYLAXIS  751 


SELF  PROPHYLAXIS. 

The  theoretical  ground  upon  which  a  patient  is  to  perform  self- 
prophylaxis  is  that  plant  life  does  not  thrive  if  disturhed  frequently,  or, 
to  put  it  in  a  different  way,  a  bacterial  collection  or  colony  capable 
of  caries  or  gingivitis  production  cannot  get  into  such  living  and 
functional  conditions  as  to  act  deleteriously  if  disturbed  every  few 
days.  For  example,  in  cane-sugar  fermentation  for  rum  production, 
the  process  requires  much  longer  to  start  when  a  scoin"ed  vat  is  used 
than  when  it  is  left  from  a  previous  fermentation.  The  proper  pro- 
phylaxis and  even  the  treatment  of  pyorrhea  proves  this  to  be  the 
case.    The  raitionale  of  self -prophylaxis  therefore  includes : 

1.  The  removal  of  food  materials  after  each  meal. 

2.  The  frequent  distiu'bance  of  microbic  plaques  mechanically  or 
chemically. 

3.  The  neutralization  of  any  acid  formed  in  locations  accidentally 
overlooked. 

The  first  two  indications  are  partly  met  by  the  use  of  the  tooth 
brush  which  should  be  small  with  fairly  stiff  bristles.  Several  good 
methods  are  employed. 

In  one  method  the  brush  is  placed  with  the  side  to  the  gum  as  in 
Fig.  694  and  turned  down  (toward  the  occlusal)  as  in  Fig.  695. 

A  second  to-and-fro  motion  over  the  cervices  as  in  Fig.  696  com- 
pletes the  brushing  of  the  gum  and  teeth  in  that  locality.  The  lingual 
of  incisors  are  to  be  cleansed  with  the  tip  of  the  brush  moved  from 
side  to  side  or  with  the  heel  of  the  brush  as  drawai  out  of  the  mouth. 
A  special  brush  with  all  bristles  but  the  end  tuft  (as  of  a  "Prophy- 
lactic brush")  cut  away  and  the  stubbie  gromid  do^^^l  is  usefid  for 
the  lingual  of  incisors  especiallj^  the  lower  when  the  gum  has  receded. 
It  has  also  some  use  in  bridgework  as  has  a  simple  cleansing  brush 
moimted  in  a  Jack  porte.  Fig.  697  shows  a  trimmed  cleansing 
brush  to  be  mounted  m  a  Jack  porte  (Fig.  619)  and  useful  for  self- 
cleansing  in  odd  situations. 

The  occlusal  surfaces  are  to  be  brushed  hard.  INIany  patients 
neglect  third  molars  through  a  downward  or  upward  sweep  of  the 
brush,  thus  passing  by  the  localit^^  The  buccal  of  the  upper  and  both 
lingual  and  buccal  of  lowers  are  frequently  decayed  for  this  reason. 
The  lingual  cervices  of  all  molars  are  often  overlooked.  The  general 
principle  that  if  the  cervices  of  teeth  are  brushed  the  rest  will  be 
cleansed  is  well  taken. 

The  second  method  is  that  of  application  of  the  bristles  in  a  rotary 
manner,  sweeping  the  brush  about  in  a  circle  as  large  as  the  cheek 


752 


PROPHYLAXIS 


will  permit  and  advancing  in  both  directions.     Fones^  recommends 
\'ery  light  pressure  and  very  rapid  motion  over  gums  and  teeth  with 


Fig.  694 


Fig.  695 


Fig.  696 


Application  of  tooth  brush.     (Luckie.) 
Fig.  697 


Trimmed  brush  to  be  used  in  Jack  porte,  Fig.  619. 
1  Mouth  hygiene,  1916. 


SELF  PROPHYLAXIS  753 

this  motion  upon  the  buccal  side  and  a  rapid  to-and-fro  motion  over 
the  entire  hard  palate,  gums  and  teeth  for  the  lingual,  allowing  the  heel 
bristles  to  wipe  the  lingual  of  the  incisors. 

The  gum  massage  so  applied  brings  blood  to  the  tissues,  inducing 
an  artificial  hyperemia  with  its  nutritive,  toughening  effect,  which 
reduces  sensitivity  of  the  tissue  and  increases  its  phagocytic  power, 
thus  rendering  it  more  firmly  adjacent  to  the  teeth  and  resistant  to 
infection.  Fones  also  regards  the  gum  as  having  a  solvent  power 
upon  calcific  granules. 

The  cleansing  before  breakfast  and  at  night  is  an  additional  pre- 
caution and  pleasure.  The  brush  itself  should  be  sterilized  after 
using.  A  good  glass  brush  holder  is  sold  in  which  a  small  portion  of 
paraform  may  be  placed  in  the  lower  part  and  is  capped  with  a  metal 
screw  cap.  In  this  the  brush  may  remain  until  again  needed.  It  has 
been  shown  that  the  ordinary  brush  contains  one  or  more  millions 
of  bacteria  after  use.  In  health  this  may  possibly  be  negligible,  but 
it  is  irrational  to  reintroduce  pus  germs  in  the  brush  as  would  occur 
in  pyorrhea  cases. 

The  Use  of  Floss. — ^The  proper  use  of  floss  silk  completes  the  fric- 
tional  effort  begun  by  the  brush  and  dentifrice.  Theoretically  either 
it  or  a  rubber  band  should  be  applied  after  each  meal  to  the  surfaces 
not  reached  by  the  brush.  Fortunately  the  principle  of  occasional 
thorough  removal  of  plaques  is  of  a  value  quite  equal  to  frequent 
imperfect  cleansing,  yet  while  true  it  is  perhaps  better  if  patients 
habituate  themselves  to  the  use  of  a  rubber  band  or  floss  nightly 
for  the  removal  of  food  particles  and  plaques  between  the  teeth. 

In  practical  use  floss  should  be  grasped  in  both  hands  in  such  a 
manner  as  to  suspend  the  floss  over  the  ends  of  both  thumbs  or  on 
two  fingers  or  a  thumb  and  finger  as  a  tight  rope  is  suspended  over  its 
pole  supports,  about  one  inch  of  free  floss  is  so  stretched.  The  grasp 
depends  upon  the  locality  to  be  reached.  It  is  to  be  sawed  gently 
through  the  contacts,  passed  gently  under  one  gum  festoon,  bent 
around  the  neck  as  far  as  possible  and  drawn  back  and  forth  as  it 
passes  toward  and  out  through  the  contact.  It  is  then  to  be 
reinserted  at  the  same  space  and  the  adjoining  tooth  treated  in  like 
manner.  Once  or  twice  a  week  tooth  powder  or  paste  with  slight 
grit  is  rubbed  over  the  teeth  and  the  work  most  carefully  done,  every 
surface  being  considered. 

As  a  matter  of  fact  floss  will  cleanse  the  entire  approximal  and 
two-thirds  of  the  buccal  and  lingual  surface  if  correctly  used. 

The  snapping  of  floss  upon  the  gum  and  sawing  into  the  giun  should 
be  avoided.  The  septal  tissue  is  injiu-ed,  infected,  and  is  apt  to  recede; 
moreover,  the  cleansing  is  not  accurately  done.    In  case  of  recession  of 

48 


754 


PROPHYLAXIS 


upper  or  lower  gums  there  is  a  method  of  flossing  by  passing  through 
two  approximal  spaces,  crossing  the  ends  and  puUing  on  each  altern- 
atel3^  I  have  had  a  clear  case  of  notched  lingual  and  approximal  abra- 
sion caused  within  six  months  by  this  method.  It  was  not  successful 
in  cleansing  the  actual  cervix  at  the  gum.  In  case  of  rapid  formation 
of  calculus  this  may  have  to  be  done  daily.  If  there  is  any  difficulty 
in  the  use  of  floss,  any  rough  filling  etc.,  should  be  made  smooth  at 
the  contact  and  any  overhang  removed. 

Fig.  698 


Simple  porte-polisher.     One,  shoe  peg  trimmed. 

The  twisted  wire  bodkin  shown  in  Fig.  699  is  very  valuable  as  a 
means  of  threading  floss  through  a  bridge  space.  Being  readily  bent 
into  a  half  circle  it  returns  toward  the  lips  so  as  to  be  readily  grasped. 
It  should  be  bent  in  line  with  the  flatness  of  the  eye.  To  make  them 
take  the  temper  from  a  thin  shank  like  that  of  an  old  Gates-Glidden 
drill,  bend  it  into  the  form  of  a  button  hook;  over  this  loop  a  six  inch 
length  of  fine  regulating  wire.  Revolve  the  hook  in  the  engine  and 
run  the  wire  through  the  fingers  of  the  left  hand.  The  bodkin  is  run 
through  any  bridge  space  and  the  doubled  floss  used  with  or  without 
powder  or  paste. 

Fig.  699 


Flexible  wire  bodkin  slightly  enlarged. 


The  Use  of  the  Wood  Point  or  Special  Brush. — That  part  of  the  tooth 
uncleansed  by  the  floss  and  often  uncleansed  by  the  brush  which  a 
wood  point  or  special  brush  will  reach  is  the  buccal  and  lingual  cervix, 
an  area  which  is  one  of  the  three  points  of  inception  of  caries  and 
gingivitis. 

A  Skinner,  Harrell,  Jack  or  the  author's  point-holder  may  be  used. 
The  last  named  consists  of  a  tube  of  nickelled  brass,  bent  at  one  end 


SELF  PROPHYLAXIS  755 

to  an  angle  of  45  degrees  (Fig.  698).  It  holds  small  shoe  pegs.  It 
can  be  used  in  cleansing  the  lingual  of  bridge-work. 

It  is  exceedingly  difficult  to  instruct  patients  in  the  proper  use 
of  the  wood  point,  but  once  properly  instructed  the  results  are 
little  short  of  marvellous.  In  use  it  is  to  be  held  in  the  hand  as 
though  using  the  Spencerian  system  of  penmanship.  The  third 
and  little  finger  rest  upon  the  chin  or  teeth  as  a  fulcrum.  The 
point  is  first  adjusted  at  the  distal  of  the  third  molar  and  with  a 
rocking  motion  of  the  hand  it  is  drawn  along  the  cervix.  The  rule 
is  to  "keep"  on  the  tooth  but  "feel"  the  gum.  Jumping  from  the 
buccal  of  one  tooth  to  another  is  to  be  avoided.  The  point  should 
be  deliberately  but  gently  drawn  (not  rubbed),  until  it  rests  in  the 
interspace.  Next  the  fulcrum  fingers  are  slightly  shifted  and  the 
next  tooth  cleansed. 

When  the  anterior  teeth  are  reached,  the  patient  should  begin 
again  at  the  third  (or  last)  molar  of  the  opposite  side.  The  motion 
is  repeated  upon  the  lingual  surface.  In  no  case  should  sight  be 
depended  upon.  The  sensation  of  contact  is  the  best  guide.  As  a 
means  of  instruction  of  the  patient,  a  disclosing  stain  may  be  used. 
If  desirable,  the  patient  may  occasionally  use  the  stain  as  a  means  of 
self-instruction.    The  brush  Fig.  697  is  mere  readily  used  by  patients. 

Dentifrices. — ^The  composition  of  the  dentifrice  if  not  too  abrasive 
seems  of  less  value  than  its  accurate  application  mth  the  brush  and 
floss.  Patients  who  use  liquid  preparations  only  do  not  seem  to  do  as 
well  as  those  using  powder  or  paste  probably  owing  to  a  lack  of 
friction.  Of  these  preparations  there  are  great  numbers  mostly 
harmless  and  useful. 

Pickerill  has  contended  that  antiseptics  are  of  doubtful  value  and 
that  ordinary  alkaline  dentifrices  depress  the  flow  of  saliva  and  that, 
on  the  other  hand,  an  acid  dentifrice,  as  acid  potassium  tartrate  in 
1  to  200  solution,  increases  the  flow  of  alkaline  saliva,  which  being 
continuous  neutralizes  any  acid  formed.  As  aside  from  a  detergent 
action,  alkalinity  is  the  object  sought  in  a  dentifrice,  the  method 
seems  rational,  especially  as  he  has  found  that  the  acid  does  not  injure 
the  teeth. 

Of  his  formulae  the  following  is  said  to  be  the  most  agreeable: 

I^ — Potassii  bitartratis  (P.  tartratis  acidi,  B.  P.)      .      .      .      gr.  ij 

Acidi  tartarici gr.  j 

Olei  limonis Ill  iij 

Glusidi  (saccharini) gr.  J 

AquEB ad  fgj — M. 

The  contentions  of  Pickerill  are  based  upon  his  observations  of 
immunes,  and  experiments  which  curiously  enough  do  not  seem  to 


756  PROPHYLAXIS 

include  definite  experimental  applications  to  any  particular  indi- 
vidual susceptible  to  caries.  It  is  seemingly  becoming  the  fashion 
to  claim  that  prophylaxis  is  a  failure  (Pickerill  admits  its  occasional 
value),  which  will  not  be  admitted  for  a  moment  by  any  one  who 
has  conscientiously  performed  it  each  three  months,  or  oftener,  with 
reasonable  assistance  from  the  patient  (see  footnote  page  268) .  Anti- 
septics are  also  denied  a  value,  but  even  Pickerill  admits  their  value 
in  oral  sepsis,  so  why  can  they  be  valueless  in  caries.  They  produce 
a  disturbance  in  the  medium,  slight  changes  in  which  are  known  to 
affect  bacteria,  a  fact  taken  advantage  of  by  Pickerill  as  a  claim  for 
acid  value.  If  disturbance  of  medium  is  of  value,  the  frequent  break- 
ing up  of  plaques  theoretically  should  be  of  immense  value  and  in 
practice  so  proves. 

Antiseptics  have  been  shown  to  reduce  general  oral  infection  to 
a  possible  minimum  when  oral  cleanliness  is  conjoined  with  their 
faithful  use,  but  without  exact  prophylaxis  cannot  be  depended  upon. 

The  writer  has  found  phenol  sodique,  1  to  7  of  water,  a  useful 
adjunct  in  this  connection  and  as  an  occasional  germicide  to 
promote  the  action  of  milder  antiseptics,  the  following  mercuric 
chloride   wash  used  for   the  space   of   two   minutes   is  valuable:^ 

T^ — Mercuric  chlorid gr.  vj 

Thymol gr.  ij 

Menthol gr.  v 

Oil  eucalyptus gtt.  x 

Glycerin fgij 

Alcohol fgij 

Auqse  gaultherise q.  s.  ad.     Oij — M. 

S.— Use  as  directed  as  mouth  wash. 

Waas,  by  careful  test,  suggests  that  a  mouth  may  be  almost,  if  not 
quite  sterilized  for  a  time  by  the  use  of  trichloride  of  iodin,  1  to  1000 ; 
(for  formulas  see  page  613.)  Gies^  has  agreed  that  soap  solution, 
sodium  carbonate  and  limewater  dissolve  flocculent  mucin  deposits  but 
not  the  harder  more  adhesive  collections.  They  should  be  valuable  in 
dentifrices  if  the  teeth  are  kept  always  free  of  old  collections. 

The  writer  has  found  much  value  in  the  use  of  a  potassium  chlorate 
paste.  This  certainly  has  kept  black  stain  from  teeth  which  usually 
accumulated  strong  evidence  of  it  within  two  weeks  of  prophylaxis, 
and  caries  is  apparently  much  lessened  by  its  use  though  prophy- 
laxis is  a  confusing  factor.  Potassium  chlorate  has  been  condemned 
by  dentists  of  high  standing  as  systemically  injurious,  but  whether 
such  small  doses  as  might  be  swallowed  after  tooth  cleansing  could 
be  injurious  has  not  been  scientifically  shown.    On  the  other  hand 

'  C.  R.  Jackson,  Dental  Summary,  1904. 

2  Journal  of  Allied  Dental  Societies,  September,  1914,  p.  408. 


SELF  PROPHYLAXIS  757 

experiments^  have  been  made  on  puppies  which  received  thirtj^  grams, 
daily  for  six  weeks,  were  then  killed  and  no  renal  lesions  were  found; 
the  gastric  mucosa  showed  no  signs  of  irritation  nor  the  blood  any 
methemoglobinemia,  and  the  animals  showed  normal  growth.  While 
large  doses  may  have  been  injurious  to  humans  this  is  entirely  different 
from  minute  residue  in  the  mouth.  As  a  matter  of  fact,  if  the 
mouth  be  washed  out  with  water  no  appreciable  toothpaste  need  be 
swallowed.  The  alternate  use  of  Pepsodent  and  Pyorrhocide,  both 
well-known  preparations,  has  also  been  markedly  prophylactic  of 
caries  and  pyorrhea. 

The  use  of  chewing  gum  after  meals  has  been  of  value  in  suscep- 
tibles.  Either  it  acts  by  friction,  removing  fermentable  food  or  by 
promoting  a  free  flow  of  saliva;  perhaps  in  both  w^ays. 

The  vigorous  mastication  of  food  stimulates  the  flow  of  saliva  as 
well  as  cleanses  the  teeth. 

Whether,  however,  it  shall  be  best  in  the  future  to  prescribe 
a  weak  organic  acid  as  a  dentifrice  and  trust  to  the  flow  of  alkaline 
saliva  or  use  a  weak  alkaline  wash,  as  lime-water  one-half  strength, 
or  even  an  alkaline  tooth  powder  or  paste  must  be  decided  by  actual 
clinical  experiment  upon  susceptibles,  as  immunes  are  valueless  for 
observation  unless  they  lapse  from  immunity.  Even  here  the  credit 
must  not  be  given  altogether  to  the  acid  treatment  side  of  the  con- 
tention unless  prophylaxis  is  eliminated.  In  brief,  the  whole  sub- 
ject requires  intelligent  ventilation.  We  have  to  thank  Pickerill 
and  Gies,  working  on  this  line,  for  at  least  a  new  departure  in  our 
thinking  regarding  dentifrices.  In  some  cases  good  results  are 
obtained  through  the  use  at  night  of  the  milk  of  magnesia.  It  alka- 
linizes  the  mouth,  reducing  any  acid  accidentally  formed  in  localities 
not  reached  by  the  brush. 

Finally  a  dietary  should  be  outlined  which  shall  be  proper  for 
general  health,  shall  reduce  the  carbohydrate  element  remaining  in 
the  mouth  (as  candy  and  cracker  consumption  between  meals), 
and  shall  induce  a  flow  of  alkaline  saliva  after  meals.  In  this  con- 
nection the  use  of  acid  fruit  as  a  stimulant  to  a  continuous  flow  of 
alkaline  saliva  after  meals  and  vigorous  mastication  for  its  cleansing 
and  saliva  stimulation  are  to  be  considered. 

The  teeth  should  receive  all  needful  care  during  pregnancy,  that 
the  mother  should  not  suffer  pain,  but  work  should  be  of  a  temporary 
nature,  if  necessary,  to  avoid  shock,  especially  at  about  the  third 
month  of  gestation.  Attention  has  been  called  to  the  fact  that 
during  menstruation  a  systemic  hyperacidity  exists,  which  can  be 

1  Medical  Brief,  December,  1912. 


758  PROPHYLAXIS 

combated  by  the  use  of  lime  internally  and  milk  of  magnesia  or 
lime  water  locally. 

In  the  care  of  the  teeth  during  pregnancy  the  effect  of  the  h}^dro- 
chloric  acid  vomitus  upon  the  teeth  should  be  considered,  an  alkaline 
wash  such  as  lime  water  or  bicarbonate  of  soda  solution  to  be  used 
after  the  vomiting.  The  same  would  be  true  of  seasickness  and  after 
the  use  of  any  acid  drug  or  foodstuff,  such  as  tincture  of  ferric  chloride 
or  buttermilk  in  case  the  latter  is  a  constant  diet.     (See  page  263.) 

PROPHYLAXIS  OF  SYSTEMIC  DISEASE. 

By  following  out  prophylaxis  against  incipient  caries  the  infection 
and  death  of  pulps  with  the  tendency  to  production  of  apical  abscess 
now  so  common  can  be  obviated  in  a  large  percentage  of  cases.  This  in 
turn  obviates  systemic  infection  following  these  conditions.  The  same 
is  true  of  gingivitis.  In  addition  if  treatment  of  root  canals  become 
necessary  it  is  important  that  all  work  should  be  done  in  the  most 
complete  manner  possible  under  the  conditions  and  under  the  strictest 
asepsis  reinforced  by  antisepsis  so  that  no  septic  focus  shall  be  insti- 
tuted by  operation.  Teeth  which  show  any  signs  of  being  a  possible 
source  of  general  infection  through  blind  abscess  or  granuloma  should 
be  radiographed  and  either  treated  to  a  cure  by  all  means  indicated 
or  extracted.  Those  supposedly  cured  should  be  radiographed  occa- 
sionally as  a  prophylactic  precaution  and  handled  according  to  indi- 
cations. In  this  connection  pyorrhea  pockets,  faulty  fillings,  crown 
and  bridge  bands  and  the  underlying  septic  cement  and  other  sources 
of  sepsis  of  less  obvious  nature  should  be  considered  as  possible 
foci  involving  systemic  complications  and  changed  to  hygienic  con- 
ditions. In  view  of  these  possibilities  work  of  a  nature  least  liable  to 
induce  complications  should  be  done  and  those  liable  to  produce 
them  in  time  avoided.  (See  recurrence  of  caries,  gangrene,  abscess 
and  pyorrhea  for  details.  Also  chapter  on  Infections  from  the 
Mouth.) 

PROPHYLAXIS  OF  MALOCCLUSION. 

It  has  been  shown  that  general  malocclusion  resulting  in  a  necessity 
for  orthodontia  may  by  suitable  means  be  prevented  from  reaching 
its  ultimate  degree  if  treated  early.  Habits  such  as  thumb,  lip  and 
tongue  sucking  should  be  corrected  as  soon  as  noticed  (see  page  94), 
otherwise  malocclusion  may  occur. 

If  adenoids  or  other  nasal  obstruction  be  a  likely  cause  of  mal- 
occlusion of  this  type,  they  should  be  removed  early.     Mechanical 


PROPHYLAXIS  OF  DENTITION  759 

corrections  if  required  are  purely  operative  and  the  reader  is  referred 
to  works  upon  this  subject.^ 

The  gradual  loss  of  teeth,  especiall}'  the  posteriors,  frequently 
throws  undue  strain  upon  the  pericementi  of  the  remaming  teeth. 
The  results  are  overwork,  pericementitis  and  abrasion.  Proper 
support  of  the  opposing  arches  is  the  prophylactic  measure.  Indi- 
vidual malocclusion  or  overuse,  pyorrhea,  etc.,  have  to  be  considered 
in  connection  with  overwork  of  teeth  and  the  reader  is  referred  to  the 
chapters  on  these  for  prophylactic  indications. 

In  orthodontia  with  fixed  appliances  sprays  are  to  used  to  remove 
fermentable  particles.  These  are  also  useful  in  pyorrhea  (for  illustra- 
tion see  Asepsis). 

PROPHYLAXIS  OF  EROSION  AND  ABRASION. 

In  these  conditions  any  possible  local  and  systemic  causes  should 
be  sought  and  combated  and  antacids  used  locally  (see  pages  200  and 
214). 

PROPHYLAXIS  OF  DENTITION. 

The  possible  causes  of  malnutrition  possibly  affecting  the  first  or 
second  dentition  have  been  as  fully  discussed  as  present  knowledge 
permits.     In  brief,  causes  should  be  antagonized  if  possible. 

It  has  been  shown  that  during  pregnancy  osteomalacia  may  occur, 
and  that  it  represents  a  demineralization  by  decalcification  of  the 
bones  of  the  mother.  Whether  or  not  this  may  influence  caries  of 
enamel  is  not  certain,  though  acid  secretions  occur  from  the  gum 
margins,  but  there  is  no  reason  why  the  resistance  of  the  fibrils  of 
the  dentin  should  not  be  lessened,  or  even  that  the  dentin  may  not 
be  to  an  extent  demineralized,  as  positively  claimed  by  some  accurate 
observers  (Black  to  the  contrary).  An  excessive  osteomalacia  may 
be  held  to  represent  a  deficiency  of  osteogenetic  nutritive  material 
for  the  child.  This  would  lead  to  an  inferior  development  of  the 
child's  temporary  teeth. 

Any  abnormal  condition  of  the  mother  should  be  corrected,  if 
possible,  in  order  that  her  general  nutrition  and  that  of  the  child 
may  not  suffer. 

Probably  upon  the  congenital  constitution  of  the  child  depends 
much  of  its  future  susceptibility  or  immunity  to  caries. 

Accepting  the  decalcification  theory  of  osteomalacia,  the  use  by 
the  nursing  or  gravid  mother  of  mild  alkalies  internally,  such  as  a 

1  See  article  by  J.  Lowe  Young,  Dental  Cosmos,  1917,  p.  23;  also  Jour.  Nat.  Dental 
Association,  August,  1917. 


760  PROPHYLAXIS 

tablespoonfiil  of  lime  water  repeated,  and  the  use  of  lime-containing 
foods,  as  the  cereals,  and  mineral  waters  as  beverages,  cannot  but  be 
of  values  as  antacids  furnishing  a  neutralizing  agent  for  the  acid, 
while  the  lime  probably  enters  into  the  development  of  bone  (Hare), 
and,  therefore,  would  be  useful  in  supplying,  via  the  placenta, 
mother's  milk,  and  later  the  child's  food,  the  element  needed  for  the 
development  of  teeth.  The  use  of  glycerophosphate  of  lime  and  soda 
has  been  suggested. 


CHAPTER   XXVI. 
DENTAL  RADIOGRAPHY. 

The  great  and  increasing  importance  of  radiography  as  a  means 
of  diagnosis  and  as  an  indication  for  therapeutics,  warrants  a  brief 
chapter  in  this  book.  A  correct  diagnosis  is  always  the  first  prin- 
ciple in  therapeutics  and  may  save  much  time,  labor  and  chagrin. 
Roentgenology,  radiology,  radiography,  skiology,  skiagraphy,  a;-ray 
diagnosis  to  give  it  its  A-arious  names  consists  in  the  projection  of  the 
.T-rays  discovered  by  Roentgen  in  1896,  as  a  part  of  the  radiant 
emanations  from  a  Crookes's  tube  through  the  more  or  less  permeable 
tissues  of  a  part  of  the  body  and  thence  upon  a  photographic  plate 
or  celluloid  fibn  upon  which  the  sHver  in  the  albuminate  of  silver 
emulsion,  coating  the  plate,  is  precipitated.  Upon  development  ui 
proper  solutions  this  is  found  darkened  in  proportion  to  the  amount 
of  a'-rays  which  haA'e  acted  upon  it.  If  the  tissues  were  equally 
permeable  by  the  a-ray  the  plate  would  be  a  uniform  black,  but  as 
penetrable,  impenetrable  or  semipenetrable  substances  exist  together 
as  instanced  in  the  mouth  by  gimi  tissue,  metal  fiUings,  etc.,  and 
cancellous  bone  or  teeth,  each  intercepts  the  light  rays  in  different 
degree,  hence  the  different  effects  upon  parts  of  the  plate  produces 
a  grading  or  a  picture  from  which  by  correct  interpretation  informa- 
tion may  be  gained. 

Roentgenology  also  includes  the  application  of  the  roentgen  rays 
in  the  therapeutics  of  disease  as  they  have  a  stimulant  effect  upon 
living  ceUs,  increasing  their  bactericidal  powers,  but  m  cells  of  low 
■sdtality,  such  as  tumor  cells,  they  can  produce  a  desirable  degenera- 
tion and  necrosis  while  the  more  highly  vitalized  cells  are  merely 
stimulated. 

In  the  therapeutics  of  the  more  superficially  located  diseased  tissues 
this  principle  has  wide  application.  They  also  affect  superficial 
healthy  tissues  unfavorably  if  these  are  "  binned"  acutely,  or  if  many 
applications  of  shorter  duration  are  made  as  in  the  "dermatitis" 
of  operators  or  even  then*  sterilization. 

There  are  many  reasons  wh}'  an  operator  should  take  his  own 
radiographs,  principally  these  (1)  He  knows  what  he  wishes  radio- 
graphed; (2)  he  obtains  the  radiograph  without  loss  of  more  time  than 

(761) 


762  DENTAL  RADIOGRAPHY 

consumed  in  gi^■ing  instruction  to  a  radiographer;  (o)  the  expense 
to  the  patient  can  be  controlled  if  such  is  a  professional  consideration 
and  as  many-  radiographs  taken  as  judged  necessary  and  at  the  proper 
crisis;  (4)  he  receives  the  benefit  of  the  impression  made  upon  the 
patient  himself,  a  matter  of  importance  m  carrying  on  a  treatment; 
(5)  such  profits  as  may  accrue  are  his. 

For  dental  piu-poses  the  apparatus  should  be  efficient,  of  simple 
construction  and  thus  readily  cared  for,  and  so  constructed  as  to  be 
rapidly  used  without  alarming  the  patient.  Danger  to  the  operator 
is  usually  avoided  by  the  use  of  a  lead  screen  impermeable  to  the  rays. 
Statements  of  manufacturers  as  to  the  safety  of  lead  glass  are  easily 
corrected  by  Kell's  method  of  wrapping  a  film  packet  with  wire, 
placing  it  in  the  position  the  operator  is  supposed  to  occupy  and 
developing  after  a  few  exposures.  It  will  probkbly  be  found  that  it 
has  been  affected  as  in  such  case  will  the  operator  be. 

The  use  of  a  lead  screen  is  always  ad\-isable.  In  any  case  where  a 
spark  might  jump  to  the  patient  a  rubber  mat  should  be  interposed. ^ 
In  use  no  contact  of  the  patient  with  any  metal  portion  of  the  instru- 
ment should  be  allowed,  e.  g.,  the  cord  wheel  or  its  connections  as  a 
shock  may  be  produced.  No  shock  is  produced  by  contact  with  the 
adjustable  arm  or  aluminum  filter,  as  these  are  practically  insulated. 

If  the  "soft  rays"  which  are  the  non-penetrating  .r-rays,  irritating 
to  tissue  should  be  excluded  an  aluminum  filter  is  interposed  which 
intercepts  them  while  the  "hard"  or  penetrating  rays  pass  on  to  and 
through  the  patient's  tissues. 

The  .T-ray  apparatus  used  by  the  operator  should  be  operated  as 
per  the  directions  of  the  manufacturers  as  instruments  differ  in  con- 
struction and  power  and  are  constantly  changing  in  character.  Xo 
dark-room  is  now  required  for  their  use.  In  general  terms  (1)  the 
patient  should  be  posed  seated  or  standing;  (2)  the  instrument  ad- 
justed to  the  proper  height,  angle  and  central  "focus";  (3)  the  tube 
flashed  once  to  ascertain  if  in  working  order  and  to  cahn  the  patient; 
(4)  the  packet  or  plate  properly  adjusted  and  the  patient  cautioned  to 
remain  quiet;  (5)  the  exposure  made  and  the  packet,  etc.,  removed. 

Taking  the  Radiograph. — Two  forms  of  radiograph  may  be  obtained, 
the  plate  and  the  celluloid  film.  In  searching  for  wholly  miknown 
conditions,  for  example,  an  impacted  tooth  in  uncertain  location,  the 
plate  may  be  better.  ^Yith  this  method,  the  plate  wrapped  in  black 
paper  is  placed  upon  one  side  of  the  face,  the  jaws  are  opened  and  the 
exposure  made  from  the  opposite  side.  The  rays  pass  from  tube  to 
plate  and  the  radiograph  shows  all  structures  in  relation,  but  there 

1  Raper;  Dental  Radiography. 


TAKING  THE  RADIOGRAPH  763 

is  apt  to  be  siiperimposition  of  tlie  teeth,  etc.,  of  one  side  upon  tliat 
of  the  other.  However,  if  the  detail  be  sufficient,  a  diagnosis  can  be 
made  or  strong  suspicion  obtained,  which  can  be  confirmed  by  the 
other  method  of  using  a  celhdoid  fihn,  which  is  used  in  fairly  suspected 
conditions.  In  this  latter  method  two  celluloid  films,  about  l\  inch 
by  1^  inch,  with  their  emulsion  surfaces  together  are  wrapped  in  black 
paper  to  exclude  the  light  and  again  in  waxed  red  paper  to  exclude 
moisture,  or  the  films  are  enclosed  in  unvulcanized  black  dental 
rubber.  This  covering  permits  the  trimming  of  the  film  in  the  dark- 
room or  box  so  that  a  better  fit  is  obtained.  The  edges  are  then 
pinched  together.^ 

The  Buck  "X-ograph"  film  has  seemed  to  the  writer  to  give  the 
most  reliable  results,  though  others,  no  doubt,  prefer  other  makes. 
This  has  a  lead  or  tin  and  lead  frame  which  has  two  films  and  a 
strip  of  black  paper  held  within  it  by  being  stamped  over  their  edges. 
The  black  paper  is  exposed  like  a  picture  in  its  frame  and  the  metal 
backs  the  enclosures  and  is  said  to  reflect  the  rays,  thus  intensifying 
the  effect  upon  the  film.    It  is  readily  adapted  and  held  in  the  mouth. 

This  packet  is  inserted  within  the  mouth  in  proper  position  to 
receive  the  shadows  of  the  teeth  and  adjacent  parts.  It  is  held  by  the 
finger  or  thumb  of  the  patient,  the  rest  of  the  hand  being  kept  out 
of  range  of  the  .T-rays  passing  to  the  negative.  The  correct  angle 
of  the  rays  having  been  previously  determined,  the  exposure  is  made 
for  a  predetermined  number  of  seconds.  The  small  intraoral  radio- 
graph gi^'es  greater  detail  of  the  area  under  consideration  and  is 
usually  employed.  From  three  to  five  teeth  may  be  radiographed 
on  one  film,  the  most  important  being  centered.  For  an  entire  mouth 
usually  ten  serial  radiographs  are  taken.  If  the  patient  gag,  as  occa- 
sionally occm"s,  a  solution  of  novocain  may  be  painted  on  the  mucous 
membrane.  Radiographs  are  usually  mounted  on  a  convenient  card 
having  apertures  covered  with  opalescent  celluloid,  permitting  the 
transmission  of  a  soft  light  for  examination.  These  cards  usually 
have  descriptive  printing,  identifying  the  part  of  the  mouth  radio- 
graphed, or  it  may  be  written  on  the  card.  Examination  is  made  by 
holding  the  film,  mounted  or  not  toward  the  strong  daylight  or  in 
front  of  an  electric  bulb. 

The  Angle  of  the  Rays. — Owing  to  the  conformation  of  the  hard 
palate  in  order  to  obtain  a  corresponding  length  of  an  upper  tooth 
and  its  radiograph,  an  angle  of  about  45  degrees  with  the  tube  center 
to  the  axis  of  the  root  should  be  observed  well  toward  the  apex.  An 
angle  of  90  degrees  or  more  lengthens  the  tooth  in  the  radiograph. 

1  Kells:  Johnson's  Operative  Dentistry, 


764  DENTAL  RADIOGRAPHY 

In  the  lower  jaw  from  cuspid  to  cuspid  an  angle  of  about  120  degrees 
to  the  axis  of  the  tooth  is  necessary  owing  to  the  inclination  of  the 
film  toward  the  lingual.  The  lower  bicuspid  and  molars  may  be  taken 
at  about  90  degrees.  Kells  suggests  that  the  angle  be  determined  at 
the  chair  and  a  spot  made  on  the  face  with  a  blue  pencil  as  a  focal 
spot  for  the  x-rays. 

These  angles  may  be  changed  to  obtain  certain  details.  For 
example,  it  may  be  more  important  to  obtain  details  of  the  apical 
regions  of  an  upper  molar  than  the  exact  root  length. 

Radiographs  should  be  taken  at  opposite  angles  in  upper  first 
bicuspid  or  molars  as  the  two  roots  may  superimpose  their  shadows. 
The  length  of  exposure  should  be  measured  in  seconds  by  the  watch 
or  a  count  at  about  known  speed  and  varies  from  one  to  ten  seconds 
according  to  apparatus,  density  of  tissues  and  details  desired.  With 
an  apparatus  having  the  aluminum  filter,  even  sixty  seconds  are  safe, 
but  unnecessary.  An  Eastman  standard  film  requires  three  seconds. 
The  Buck  about  the  same,  though  the  "speed"  packets  require  less. 
To  identify  the  films  pencil  the  name  and  the  location  radiographed 
on  the  paper  wrapper  ot  imprmt  it  with  pencil  on  the  metal  casing. 

Developing  the  Radiograph. — The  operator  may  prefer  his  own 
solutions  but  the  developing  and  hypo  solutions  sold  as  Eastman's 
are  satisfactory  and  convenient,  when  made  up  according  to  direc- 
tions. To  develop,  say  a  half  dozen  or  more  negatives  the  writer 
proceeds  as  follows:  The  films  in  their  wrappers  are  laid  in  a  pile  in 
the  center  of  the  top  of  the  developing  "dark  box"  and  the  watch 
laid  in  full  view.  The  proper  cups  are  filled,  two  with  developer, 
two  with  hypo  and  one  with  tap  water,  all  should  be  below  65°  F., 
and  in  hot  weather  be  chilled  by  placing  in  a  pan  containing  ice-water. 
Each  should  be  in  a  customary  position. 

An  open  knife  and  a  cloth  or  sponge  should  be  placed  within  and 
the  light  excluded  by  closing  the  aperture,  permitting  the  sleeves  to 
be  exposed.  Introduce  the  left  hand,  holding  one  Buck  film  and  a 
discarded  Eastman  or  other  black  paper  wrapper.  (The  extra 
wrapper  is  not  necessary  when  using  paper-wrapped  packets.) 
Insert  the  right  hand  and  grasp  the  knife  and  with  the  blade,  peel 
up  one  end  of  the  metal  casing  and  rip  out  the  enclosm-es;  put  one 
film  between  the  fingers  and  the  casing  in  the  palm  of  the  left  hand  and 
wrap  up  the  remaining  film  and  black  paper  in  the  black  paper  and 
put  it  with  the  casing;  place  the  film  to  be  developed  into  the  devel- 
oper, add  the  minutes  required  (about  seven)  to  the  time  on  the  watch, 
withdraw  the  left  hand,  place  the  packet  and  casing  on  top  of  the  box 
over  the  cup  containing  the  fihn.  Take  up  another  packet  and  paper 
and  repeat  the  process,  but  putting  the  film  into  the  other  developer 


INTERPRETATION  OF  RADIOGRAPHS  765 

cup.  Withdraw  both  hands  and  pencil  the  time  of  expiration  of  devel- 
oping upon  bits  of  paper.  Utilize  the  time  elapsing  to  enclose  each 
undeveloped  film  in  an  additional  red  paper.  Just  before  the  expira- 
tion of  the  time,  introduce  the  hands  and  prepare  a  third  film,  holding 
it  ready  in  the  left  hand.  Remove  film  No.  1  from  the  developer,  wash 
in  the  water  and  put  into  the  "hypo"  and  put  film  No.  3  in  its  place 
in  the  unoccupied  developer.  Withdraw  the  left  hand,  place  the 
packets  over  film  No.  3  and  remove  the  packets  of  film  No.  1  to  posi- 
tion over  the  hypo.  Take  up  fihn  No.  4  and  insert,  prepare,  remove 
No.  2  to  corresponding  "hypo,"  put  No.  4  in  its  place,  put  the  packets 
in  corresponding  position  on  top  of  box.  In  five  minutes  remove 
No.  1  from  the  hypo  as  follows:  Jig  loose  from  the  side  of  the  cup, 
pick  up  by  the  edge  between  forefinger  and  middle  finger  and  let  fall 
gently  into  the  palm  of  the  left  hand,  but  prevent  contact  by  holding 
the  edges  with  the  palmar  sides  of  the  fingers.  Hold  the  hand  rigid 
and  withdraw,  take  up  film  by  the  edge  with  a  spring  clip,  examine 
by  electric  light,  but  do  not  let  the  gelatin  be  melted,  wave  through 
water  in  a  bowl,  hang  on  the  edge  of  the  bowl  with  the  extra  film  and 
casing  clipped  against  the  outside  of  the  bowl.  Repeat  with  No.  2. 
The  hypo  cups  are  now  free  for  introduction  of  Nos.  3  and  4  at  the 
proper  time  (about  a  minute  later)  and  Nos.  5  and  6  can  be  introduced. 
Between  handlings  the  fingers  should  be  wiped  off.  The  films  should 
remain  in  the  water  at  least  a  half  hour,  but  may  remain  the  rest  of 
the  day.  Too  long  immersion  may  cause  the  solution  of  the  gelatin 
and  much  chagrin ;  about  twelve  films  may  be  developed  in  an  hour. 
The  extra  films  are  not  developed  unless  something  goes  wrong  or 
unless  duplicates  are  required,  in  the  latter  case  two  films  are  devel- 
oped at  once,  back  to  back.  Plates  require  dark-room  facilities  and 
may  be  developed  mider  an  orange  light  and  washed  in  running  water 
after  "fixing"  in  h^^DO.  They  might  be  done  in  the  trays  furnished. 
After  a  proper  time  in  water  the  films  are  to  be  hung  on  a  large  cord, 
as  a  double  electric  light  cord,  with  their  correspondmg  packets,  or 
on  the  edge  of  a  dry  bowl  and  allowed  to  dry.  They  are  then  mounted 
and  described  on  the  mount  or  put  into  small  envelopes  with  a  descrip- 
tion. By  this  system  the  operator  identifies  each  film  throughout 
without  mental  effort. 

The  use  of  paper  wrapped  films  differs  but  slightly  and  this  and 
other  modifications  will  suggest  themselves.  The  technic  may  easily 
be  carried  out  and  even  the  radiograph  taken  by  an  easily  trained 
assistant  though  this  latter  is  best  done  by  the  operator. 

Interpretation  of  Radiographs. — Having  been  taken  for  this  purpose 
interpretation  is  all-important,  and  while  obvious  conditions  are 
susceptible  of  correct  interpretation  by  a  radiographer,  a  clinical 


766 


DENTAL  RADIOGRAPHY 


knowledge  of  the  case  is  required  in  many  cases.  Therefore,  final 
judgment  is  best  passed  by  one  having  facilities  for  digital,  electrical 
and  other  means  of  diagnosis  at  hand.  When  a  diagnosis  rests  upon 
the  question  of  vitality  or  non-vitality  of  a  pulp,  and  the  facts  are 
not  proved  in  any  way  by  the  radiograph,  one  should  apply  the  tests 
described  on  page  493. 

In  studying  the  details  it  must  be  remembered  that  the  .T-rays 
penetrate  and  pass  through  all  substances  about  the  mouth,  except 
metals  and  certain  root  canal  fillings,  such  as  gutta-percha,  and  pastes 
containing  bismuth.  It  completely  penetrates  cotton  which  therefore 
does  not  "show"  (Fig.  700). 

Fig.  700 


Wire  wound  with  cotton  in  bicuspid.    Case  of  old  vital  pulp  stump,  perforation 

suspected. 

In  the  degree  in  which  it  passes  without  interception,  tissues  and 
substances  are  "radiolucent"  (radiolucency)  otherwise  they  are 
"radiopaque"  (radiopacity)  (Ottolengui).  The  gum,  medullary 
tissue,  mucous  membrane  and  space  in  the  antrum,  pulp  ca\'ity  and 
the  pericemental  tract  are  all  so  highly  radiolucent,  that  the  silver  in 
the  negative  is  heavily  precipitated  and  blackened.  They  show  dis- 
tinctly, however,  in  contrast  with  juxtaposed  tissues,  which  intercept 
the  light  in  some  degree.  Areas  of  resorbed  bone  or  root  and  abscess 
tracts  show  dark  in  the  negative  as  they  are  areas  of  soft  tissue  like 
pericementum.  The  trabeculse  of  bone,  the  more  cortical  bone,  the 
root  substance,  porcelain,  the  enamel  and  some  root  fillings,  as ' 
cement,  are  semi-radiolucent  and,  having  intercepted  some  light, 
show  grayish  in  the  negati^'e.  Finally  metals,  gutta-percha  and  root 
fillings  with  bismuth  practically  intercept  all  the  rays  and  show  as 
white  in  the  negative  (film),  the  silver  not  being  precipitated.  In 
a  positive  picture  all  these  are  reversed  if  shown  at  all.  With  these 
facts  and  the  anatomy  of  the  parts  known,  and  with  the  clinical 
experience  and  applied  tests  one  using  common  sense,  may  arrive  at 
a  diagnosis  often  at  once.    Certainly  after  investigation. 

Certain  facts  should  be  stated.    (From  appearance  in  the  negative 
the  opposite  of  the  illustrations.) 

The  angle  of  exposure  for  upper  teeth  often  superimposes  the  light 


INTERPRETATION  OF  RADIOGRAPHS 


767 


outlines  of  the  antrum  upon  the  radiograph  of  the  teeth.  This  is  normal 
though  often  confusing  (Fig.  701).     An  apical  abscess  or  granuloma 


Fig.  701 


Fig.  702 


on  the  teeth  superimposed  will  show  as  a  dark  area  within  this  out- 
line. In  case  of  doubt  test  for  pulp  vitality.  In  one  case  an  oral 
surgeon  questioned  the  vitality  of  a  L.  S.  2  B.  which  after  perforation 


Fig.  703 


Fig.  704 


of  a  gold  crown  demonstrated  vitality  by  sensitivity  of  dentin.  The 
nasal  cavity  occasionally  is  taken  in  a  radiograph,  but  must  not  be 
mistaken  for  a  necrosis  (Fig.  703). 


Fig.  705 


Fig.  706 


The  normal  cancellated  bone  shows  as  a  lattice  work,  the  cortical 
bone  (lamina, dura  of  the  alveolar  socket),  as  a  more  solid,  grayish- 


768 


DENTAL  RADIOGRAPHY 


white  line  or  area  (Figs.  711  and  712),  occasionally  owing  to  a  degree 
of  osteoporosity  or  perhaps  osteoclasia,  the  bone  will  have  an  indefi- 
nite dark  area  somewhat  suggestive  of  abscess  area.  AVliile  it  should 
be  carefully  considered  it  may  generally  be  excluded  owing  to  vitality 
of  the  teeth,  though  in  case  of  pain  about  the  tooth,  non-septic  peri- 
cementitis or  pericemental  abscess  (with  bone  resorption)  may  be 
considered  (Figs.  568  and  569). 

The  gums  are  often  not  shown;  rarely  a  faint  outline  is  seen.  The 
molar  in  Fig.  706  was  well  covered  with  gum  tissue.  The  perice- 
mental outline  is  black,  normally  it  is  a  narrow  strip  betAveen  grayish 
white  bone  and  more  gray  root  structure  (Fig.  705).  The  root  is 
clearly  outlined  in  good  pictm*es,  sometimes  they  are  radiolucent  and 
may  seem  absorbed,  in  which  case  another  picture  should  be  taken, 
or  careful  interior  exploration  should  be  done. 


Fig.  707 


Fig.  708 


Upper  molars  often  seem  to  show  but  one  root,  a  better  radio- 
graph at  a  different  angle  or  from  above  is  indicated  (Figs.  704,  705, 
and  707).  Root  canals  show  plainly  in  some  cases  in  others  equally 
good  canals  do  not  show.  (Fig.  708.)  This  depends  upon  their 
being  more  radiolucent  than  the  rest  of  the  root.  Their  contents 
show  when  radiopaque.  Broaches  show  plainly,  but  may  show  as  if 
in  line  with  a  canal,  yet  be  out  of  line  labiolingually.  Protruding 
broaches  and  canal  fillings  are  shown  (Fig.  709).  Diagnostic  wires 
are  shown  as  in  Fig.  409. 

A  canal  may  appear  as  though  filled,  while  an  instrument  can  be 
passed  to  one  side;  this  is  due  to  a  single  cone  not  having  been 
thoroughly  packed,  occasionally  this  space  shows  distinctly. 

Secondary  dentin  and  pulp  nodules  usually  show  as  constrictions 
of  the  pulp  chamber  or  foreign  bodies  therein  (Fig.  349) .  Sometimes 
they  do  not  show  at  all.    Cavities  are  sometimes  noted,  as  in  Fig.  708. 

Calcific  pulp  degenerations  do  not  show  well  as  a  rule.  Perfora- 
tions show  as  a  rule,  as  in  Fig.  708.  Hypercementosis  is  well  defined, 
as  a  rule  as  a  root  enlargement.     (Figs.  551  and  554.) 

Resorptions  may  be  seen  or  inferred  or  be  masked  if  co\'ered  up 
by  more  labial  structure  (Figs.  514,  522,  562  and  709). 


INTERPRETATION  OF  RADIOGRAPHS 


769 


Incipient  pericementitis  is  more  readily  diagnosed  by  s^inptoms 
and  a  strong  transmitted  light,  but  abscesses  on  apices  or  granu- 
lomas, or  perforations  show  dark  areas  in  the  negative.  Granu- 
lomas are  shown  as  sac-like  bodies  enclosed  in  a  bony  cell  (Fig.  538). 

Pyorrhea  pockets  and  lateral  resorptions  of  bone  show  as  though 
the  pericemental  tract  were  enlarged.  Confirmation  by  instrumental 
examination  should  settle  the  diagnosis  (Figs.  632  and  637).    Perice- 

FiG.   710 


mental  abscess  may  show  a  dark  area  alongside  a  root.  Fillings  may 
appear  as  though  near  or  into  a  pulp  cavity.  This  may  be  due  to 
superimposition  in  the  picture  as  when  a  small  buccal  filling  appears 
to  lie  in  a  pulp  cavity,  but  is  merely  between  it  and  the  a-rays. 
The  relations  of  deciduous  and  permanent  teeth  are  usually  distinctly 
shoTsii  as  are  impacted  teeth,  supernumeraries  or  the  absence  of  tooth 
germs  (Figs.  710  and  711).  The  condition  of  the  root  foramen  is 
also  visible  (Fig.  710). 


Fig.  711 


Fig.  712 


Imbedded  roots  are  seen  as  m  Fig.  307. 

The  gums  may  be  healed  over. 

Fractures  of  roots  can  be  noted  as  in  Figs.  249  and  483  as  can 
fracture  of  the  jaw.     The  mental  foramen  may  be  confused  with 
abscess  (Fig.  475). 
49 


770  DENTAL  RADIOGRAPHY 

There  are  many  radiographs  shown  throughout  this  book  which 
will  further  illustrate  interpretation. 

It  may,  in  brief,  be  stated  that  whenever  a  condition  exists  or  is 
suspected  in  which  a  differentiation  of  objects  may  be  looked  for, 
the  radiograph  will  be  of  use. 

There  are  numerous  details  connected  with  the  subject  of  radiol- 
ogy which  if  they  have  not  been  touched  upon  in  this  chapter 
or  in  place  in  this  book  may  be  found  in  various  text-books  of 
great  value.  Notably  Raper's  Dental  Radiography,  Kell's  chapter  on 
the  "Application  of  the  Rontgen  Ray  in  Dentistry"  in  Johnson's 
Text-book  of  Operative  Dentistry  and  Ivy's  Interpretation  of  X-ray 
Films.  The  idea  here  is  to  give  a  few  important  principles  useful  to 
those  who  make  their  own  radiographs  or  diagnose  from  those  of 
other  radiographers. 


CHAPTER  XXVII. 
APICOECTOMY  AND  ROOT  AMPUTATION. 

Apicoectomy  or  apexotomy  may  be  defined  as  the  surgical  removal 
of  the  root  apex,  and  is  a  partial  root  amputation  or  resection. 

Root  amputation,  while  including  apicoectomy,  might  specifically 
be  defined  as  the  removal  of  an  entire  root  at  its  junction  with  the 
crown,  and  can  be  performed  only  on  a  multirooted  tooth.  The  object 
of  these  operations  is  to  save  a  tooth  from  extraction  by  removing  a 
part  or  ail  of  a  root  so  diseased  as  to  be  otherwise  incurable,  including 
in  this  protruding  broaches  irritating  root  fillings  and  inaccessible 
perforations  all  of  which  have  led  or  may  lead  to  untoward  disease. 
It  has  been  suggested  that  all  roots  not  capable  of  fiUing  to  the  end 
should  be  immediately  apicoected.  The  writer  does  not  believe  this 
practical  largely  because  patients  will  not  submit,  but  there  can  be 
no  surgical  objection. 

For  the  same  reason  many  prefer  extraction  to  any  amputation 
and  in  view  of  the  total  imcertainty  of  root  canal  treatment  it  would 
seem  that  extraction  and  bridge  or  plate  v/ork  in  most  cases  of  root 
disease  not  amenable  to  careful  treatment  is  often  the  advisable 
procedure. 

The  operation  has  been  objected  to  in  toto  by  some  prominent 
dentists  which  seems  equally  irrational.  The  operation  therefore 
seemed  limited  by  the  following  considerations: 

1.  The  necessity  for  its  employment  as  a  means  to  a  cure. 

2.  The  feasibility  in  consideration  of  the  location  of  the  root  in 
question. 

3.  The  willingness  of  the  patient  to  prefer  the  operation  to  a  sub- 
stitute tooth. 

The  conditions  favoring  apicoectomy  are: 

1.  Incurable  apical  abscess  or  granuloma  or  cysts  including  apical 
perforations  protruding  broaches  or  root  filling,  etc. 

2.  Curved  or  inoperable  root  ends  with  probable  delta-like 
foramina. 

3.  Limited  apical  hypercementosis. 

4.  Limited  apical  root  resorption.  All  these  in  locations  reason- 
ably operable  in  case  of  teeth  otherwise  not  involved. 

The  conditions  favoring  root  amputations  are: 

-■■■  ;  '  (771) 


772  APICOECTOMY  AND  ROOT  AMPUTATION 

1.  Ad\'anced  pyorrhea  involving  or  closely  approaching  the  apex, 
especially  when  the  rocking  of  the  tooth  draws  the  root  out  of  its 
socket  and  returns  it  to  place. 

2.  Apical  abscess  discharging  along  the  root  at  the  gum  margin 
which  finally  is  about  the  same  as  Class  1. 

3.  Perforations  in  the  gingival  third  of  the  root  not  amenable  to 
treatment  or  pre^'enting  proper  treatment  of  the  apical  portion  of  the 
root. 

If  all  considerations  indicate  the  operation  of  apicoectomy  the 
root  canal  should  be  sterilized  at  least  as  far  as  the  intended  excision 
by  formalin  or  other  applications  repeated  daily  until  sterility  of  the 
root  interior  is  assured  or  Howe's  treatment  may  be  used.  The 
root  is  then  filled  under  strictly  aseptic  precaution  with  solidly 
packed  gutta-percha  points  using  either  eucalyptol,  oil  of  cajuput, 
xylol  or  a  xylol  solution  of  gutta-percha  or  chloropercha  as  a 
solvent  in  very  small  quantity  merely  moistenmg  the  root.  Prinz^ 
prefers  a  thin  zinc  chlorid  cement  followed  by  a  cone  of  gutta- 
percha as  rendering  disturbance  of  the  cone  less  likely.  It  does 
not  matter  if  the  filling  pass  through  the  apical  opening  or  perforation. 
Any  remaining  roots  are  of  coiu-se  properly  filled.  The  root  is  now 
ready  for  the  surgical  procedure  if  any  remaining  roots  are  deter- 
mined to  be  in  good  condition.  In  root  amputation  the  remaming 
roots  are  treated  and  filled  but  the  root  to  be  excised  need  not  be 
filled  except  to  the  point  of  excision.  The  bulb  of  the  pulp  cavity 
must  be  filled  in  this  case.  A  good  radiograph  is  obtained  if  not 
already  done,  so  that  one  may  be  guided  by  it. 

The  Operation  of  Apicoectomy. — Asepsis  and  anesthesia  are  first 
secured  (see  respective  chapters) .  The  technic  of  this  operation  difters 
with  diff"erent  operators  and  depends  somewhat  upon  whether  the 
apex  is  solidly  embedded  in  bone  as  in  an  apicoectomy  for  prevention 
of  futifre  apical  abscess  (condition  2  on  page  721)  or  whether  an  area 
of  bone  has  been  removed  from  about  the  apex  by  disease  leaving  the 
apex  practically  free. 

For  the  first  condition  Levy's  operation  seems  desirable. 

1.  A  liberal  semilmiar  cut  is  made  having  its  apex  a  little  occlusally 
to  the  point  of  the  desired  resection  and  the  flap  including  the  peri- 
osteum dissected  free. 

2.  With  a  romid  bur  the  bone  is  removed  from  over  the  root  at  this 
point  and  with  a  sharp  pointed  dentate  fissure  bur  the  root  apex  is 
severed,  the  cut  sloping  obliquely  apexward  from  buccal  to  lingual 
to  give  leverage  for  an  elevator  (the  reverse  if  operating  linguaUy), 

i  Pental  Cosmos,  May,  1918,  p.  386, 


THE  OPERATION  OF  APICOECTOMY  773 

3.  With  the  round  bur  the  bone  is  now  removed  from  over  the 
apical  portion  creating  a  path  for  the  root  to  escape. 

4.  With  a  proper  elevator  inserted  in  the  oblique  cut  the  root  apex 
is  forced  buccally. 

5.  If  a  granuloma,  etc.,  exist  the  parts  are  thoroughly  curetted, 
the  remaining  root  end  shaped  and  smoothed  and  the  flap  stitched  or 
the  cavity  packed  or  a  clot  merely  induced  without  stitching  accord- 
ing to  indications  "When  a  root  apex  lies  free  either  Levy's  technic 
may  be  employed  or  that  in  more  general  use. 

1.  The  lip  or  cheek  is  held  back  by  a  retractor  in  the  hand  of  an 
assistant.  A  semilimar  cut  is  made  with  apex  crownward  and  well 
below  the  point  of  resection  chosen  but  not  too  near  the  gum  margin 
as  necrosis  of  this  may  occur.    Any  fistula  is  included  in  it. 

2.  The  flap  including  the  periosteum  is  freely  dissected  back  with 
a  periosteal  elevator  and  held  with  a  pronged  retractor.  • 

3.  Any  bone  obstructing  the  path  of  operation  is  removed  with 
pointed  fissure  or  round  burs,  though  chisel  and  mallet  are  preferred 
by  some.  There  is  no  advantage  visible  in  chisels  and  a  number  of 
disadvantages. 

4.  A  point  of  healthy  root  and  pericementum  is  selected  and  the 
root  end  cut  off  with  a  flat  or  oblique  cut  according  to  the  necessity 
for  elevation  from  its  bed.  The  writer  can  see  no  advantage  in  merely 
curetting  the  root  end  without  amputation  except  in  case  an  acute 
apical  abscess  in  the  third  stage  be  lanced  mider  anesthesia  and  a 
chance  to  curette  offer.  The  conditions  indicating  the  siu-gical  open- 
ing of  the  gum  usually  demand  apicoectomy  except  of  course  when 
merely  done  to  estabhsh  an  artificial  fistula. 

5.  The  root  is  dislodged  or  lifted  out  with  pliers  or  if  it  escape  into 
the  abscess  cavity  is  removed  with  the  ciu-ette  (Fig.  713). 

6.  The  necrotic  tissue  lining  the  abscess  cavity  is  removed  with  the 
curette  and  the  bone  thoroughly  scraped  or  burred  to  tissue  capable 
of  granulation  and  the  root  end  smoothed  and  rounded  with  sterile 
finishing  burs  or  stones. 

7.  The  treatment  of  the  abscess  cavity  varies.  The  usual  method 
is  to  thoroughly  wash  it  out  with  boiled  physiologic  salt  solution  or 
mild  antiseptics.  Next  to  draw  sufficient  blood  to  make  a  clot  filling 
the  cavity  and  then  stitch  the  wound  with  sterile  horsehair.  A  curved 
needle  and  forceps  for  using  the  same  are  necessary  for  this. 

The  mouth  should  be  kept  as  sterile  as  possible.  Prinz  has  recently 
shown  that  the  flap  can  be  pressed  into  place  and  kept  in  apposition 
by  a  pad  of  gauze  containing  an  antiseptic  solution.  The  blood  will 
coagulate  and  hold  it  in  position. 


774 


APICOECTOMY  AND  ROOT  AMPUTATION 


Fig.  713 


Fig.  715 


Portion  of  root  and  canal  filling  lying 
in   abscess    cavity    after    apecoectomy. 


Fig.  714 


f    • 


a 


Friedman's  curettes  for  oral  siirgery. 


Stellite  combination  knife  and  periosteal 
elevator.    (Prinz,  Dental  Cosmos.) 


RESULTS  OF  MODIFICATIONS  775 

Buckley  suggests  a  gauze  packing  saturated  in  euroform  paste  as 
a  protective,  stimulant,  antiseptic  and  analgesic.  After  twenty-four 
hours  it  is  removed  and  bismuth  bone  paste  injected  every  few  days 
until  the  cavity  is  filled  with  healthy  granulations.  This  would  be 
of  greater  value  in  large  abscess  cases;  but  a  blood  clot  is  the  best 
occupant  of  a  cavity  about  the  alveolar  process,  as  Nature  shows 
after  extractions. 

Modifications. — Buckley^  adopts  Schamberg's  technic  in  that  he 
makes  a  vertical  incision,  dissects  the  periosteum  and  flaps  to  each 
side  and  retracts  with  his  special  retractor  a  pair  of  pronged 
retractors  attached  to  a  sliding  telescoped  bar.  The  spring  auto- 
matically holds  the  lips  of  the  opening  apart.  He  also  prefers  the 
mallet  and  chisel. 

Results.- — ^As  recently  performed  the  results  are  satisfactory  in 
nearly  aU  cases.  The  parts  heal  without  pus  formation  though 
should  such  occur,  the  part  may  be  irrigated  daily  with  Dakin's 
solution  or  even  bone  paste  injected. 

Granulations  gradually  replace  the  clot  and  bone  gradually  replaces 
these.    (See  Figs.  528  529  and  530.) 

The  points  to  avoid  are : 

1.  Any  septic  cohticmieation. 

2.  Oversaturation  with  adrenalin,  etc. 

3.  Curetting  into  the  apical  regions  of  other  teeth  or  cutting  their 
sides. 

4.  Insufficient  curetting  of  the/Walls  of  the  abscess  cavity. 

5.  The  loss  of  the  root  end.  ^ 

6.  The  use  of  hydrogen  dioxid. 

7.  After  sepsis  of  the  mouth. 

8.  In  posterior  teeth  other  important  parts  as  the  antrum.  If  this 
be  entered  it  is  left  to  care  for  itself  any  blood  dischargmg  via  the 
nose.  One  should  not  open  into  the  antrum  except  by  accident  during 
the  curettement  as  in  the  amputation  one  should  keep  at  a  lower  level. 
Also  one  should  recognize  the  fact  at  once  and  desist  unless  the  case 
is  originally  one  of  antral  empyema,  when  a  larger  opening  removing 
all  dead  bone  should  be  made  and  the  case  treated  as  antral  (see 
page  551). 

Cysts  in  apicoectomy  cases  are  treated  as  are  granulomas  with 
the  additional  care  not  to  enter  other  cavities  or  injure  arteries,  etc. 
They  are  packed  with  gauze,  repeated  after  twenty-four  hours  and 
again  every  three  or  four  days  thereafter  until  the  cavity  is  lined 

1  Text-book  of  Dental  Materia  Medica,  and  Therapeutics,  4th  ed. 


776  APICOECTOMY  AND  ROOT  AMPUTATION 

with  epithelium.    After  a  few  packings  bone  paste  may  be  introduced. 
Prinz^  gives  the  following  directions: 

I^ — Yellow  wax 4  drams 

Cottonseed  oil 14      " 

Aristol 1       " 

"  Melt  the  wax  and  oil  in  a  porcelain  capsule  on  a  water-bath,  let  cool,  remelt  and  add 
the  aristol,  remelt  once  or  twice  until  a  perfect  mixture  is  obtained." 

"The  cavity  is  dried,  painted  with  a  mixture  of  tincture  of  iodin 
2  parts,  acetone  4  parts  and  coated  with  a  thin  film  of  sterile  paraffin 
oil.  The  bone  wax  is  melted  by  heating  the  bottle  in  very  hot  water 
and  'poured  in'  the  patient  being  posed  in  accordance  with  gravity. 

When  loosened  it  may  be  removed  and  when  the  cavity  is  well 
lined  with  epithelium  the  patient  may  be  instructed  to  wash  the  cavity 
with  warm  salt  water  by  means  of  a  soft  rubber  ulcer  syringe." 

ROOT  AMPUTATION. 

The  operation  of  removing  a  root  at  the  bifurcation  is  quite 
simple  in  case  the  particular  root  is  loose  from  pyorrhea  (see  page 
772),  but  the  removal  of  a  solidly  placed  root  is  very  difficult  unless 
a  surgical  path  for  it  is  made.  Indeed,  there  would  seem  to  be  no 
particular  use  for  the  operation  when  the  root  is  firm  except  in  case 
of  a  perforation  in  the  coronal  or  middle  third.  In  such  a  case  it  is 
best  to  make  a  vertical  cut  over  the  bone,  dissect  back  either  flap 
with  a  periosteal  elevator  and  remove  the  bone  liberally  from  over 
the  root.  Make  an  oblique  excision  of  the  root  near  the  neck  so  as 
to  favor  the  use  of  an  elevator,  brace  the  tooth  with  the  fingers  or 
opposite  teeth  and  apply  the  force.  If  necessary  modelling  compound 
may  be  adapted  over  the  tooth  (exposing  the  root  freely),  the  finger 
or  opposing  teeth  to  act  as  a  brace.  The  oblique  cut  is  smoothed  up 
later,  no  sharp  splinters  should  be  left  to  irritate.  They  are  apt  to 
form  as  the  tooth  and  root  part.  If  desired  the  face  of  this  root  may 
be  veneered  with  amalgam  to  be  polished  later. 

The  diseased  area  is  to  be  curetted  and  a  clot  dra\\Ti  and  the 
mouth  kept  as  sterile  as  possible.  If  thought  best  steresol  may  be 
painted  over  the  dried  part  (see  page  131). 

1  Dental  Cosmos,  May,  1918. 


CHAPTER   XXVIII. 
PLANTATION  OF  TEETH. 

By  plantation  is  meant  the  more  or  less  forcible  placement  of  a 
tooth  or  appliance  to  carry  one  in  a  natural  or  prepared  alveolus. 

There  are  three  varieties : 

Replantation  consists  in  the  return  of  a  tooth  to  its  more  or  less 
natural  alveolus. 

Transplantation  is  the  plantation  of  a  foreign  tooth  in  a  natural 
or  modified  alveolus  from  which  naturally  a  root  has  been  recently 
extracted. 

Implantation  is  the  plantation  of  a  foreign  tooth  or  root  or  of  an 
artificial  root  into  an  ah'eolus  specially  prepared  for  its  reception  in 
the  alveolar  bone. 

REPLANTATION. 

As  above  defined  this  is  a  very  old  operation  and  stiU  a  recog- 
nized method  of  procedure  which  is  indicated  under  the  following 
circumstances : 

1.  ^ATien  by  reason  of  an  accident  such  as  a  blow,  fall  or  accident 
in  extraction  the  tooth  is  forced  out. 

2.  When  it  is  considered  preferable  to  apicoectomy  or  root  ampu- 
tation as  a  means  of  curing  an  otherwise  incm-able  abscess,  perfora- 
tion, etc. 

The  first  indication  has  even  been  acted  upon  by  parents  who  have 
quickly  pressed  teeth  into  their  places  where  they  became  reattached. 
Reattachment  of  the  pulp  has  even  occurred.^  At  the  present  time 
an  operation  of  this  kind  could  only  be  admissible  when  teeth  are 
but  partially  removed  in  which  case  Dakin's  or  other  solutions  should 
be  used  to  irrigate  the  parts  before  returning  the  tooth  to  place  and 
later  if  pulp  death  occur  the  pulp  should  be  removed,  etc. 

When  the  tooth  is  out  it  is  often  found  that  there  is  no  fractiu-e  of 
the  alveolar  bone,  the  tooth  having  sprung  out  ow-ing  to  the  inclined 
root  and  alveolar  surfaces  as  occurs  in  elevating  in  extraction.  The 
tooth  crown  may,  howe^'e^,  be  broken  and  may  be  restored  or  any 
cavities  filled  or  a  new  crowm  arranged.  Its  pulp  should  be  removed 
and  the  canal  fiUed  to  the  end  with  gutta-percha;  asepsis  must  be 
observed  in  this. 

1  See  page  367. 

(777) 


778  PLANTATION  OF  TEETH 

Some  prefer  to  further  fill  the  root  end  \vith  a  sniall  cohesive  gold 
filling  or  a  portion  of  gold  screw.  The  writer  prefers  the  gutta- 
percha. The  root  canal  may  be  entered  from  the  apex  with  Gates- 
Glidden  drills  or  from  the  crown  later  using  the  drills. 

The  tooth  is  to  be  placed  in  an  antiseptic  solution  for  aseptic  reasons 
and  to  preserve  the  color,  for  diied  teeth  change  color  permanently. 

If  necessary  local  anesthesia  is  resorted  to.  The  mouth  is  made 
as  aseptic  as  possible  and  the  parts  thoroughly  so  (see  chapter  on 
Asepsis).  Any  clot  is  swept  out  and  the  tooth  tried  in  place.  If 
it  does  not  go  to  place  the  socket  should  be  slightly  reamed  and 
washed  out  with  a  mild  antiseptic  and  the  tooth  planted.  Kells^ 
suggests  that  a  crystal  of  resorcin  be  placed  on  the  root  end  just  before 
planting.  I  have  usually  used  diluted  phenol  sodique  1:6.  If  there  be 
difficulty  in  placing  the  tooth,  the  patient  may  bite  upon  it.  An 
impression  is  now  taken  in  modelling  composition  which  need  not  go 
much  to  the  labial  so  as  not  to  reextract  the  tooth.  A  splint  of  30 
gauge  pm-e  gold  or  33  to  36  gauge  22K  gold  is  struck  from  a  zinc  die  to 
cover  the  linguo-incisal  two-thirds  and  the  labio-incisal  fourth  of  three 
teeth.  This  is  cemented  over  the  teeth  after  careful  adaptation  and 
should  remain  for  from  six  to  eight  weeks,  as  a  rule,  when  it  can  be 
sprung  off  and,  if  the  tooth  be  not  firm,  replaced.  Hydrogen  dioxid 
should  be  freely  used  by  the  patient  and  he  may  use  a  25  per  cent, 
solution  of  Talbot's  iodoglycerol  as  a  lotion^  over  the  parts  twice 
daily.    Frequent  inspection  and  prophylaxis  are  advisable. 

Replantation  for  Disease. — The  choice  between  apicoectomy  (or 
root  amputation)  and  replantation  depends  upon  the  feasibility  of 
the  former  and  the  state  of  disease.  Perforations  in  the  cervical 
half  of  the  root  indicate  the  latter.  Multirooted  teeth  with  granu- 
lomas might  better  often  be  replanted  if  replantation  is  not  also 
contra-indicated.  The  disease  and  the  indication  are  seldom  co- 
existent; but  this  does  not  of  necessity  limit  an  operator's  range  if 
opportunity  occur. 

The  writer  has  usually  preferred  to  extract  and  cut  off  the  necrotic 
root  end  and  await  a  healhig  process  before  replantation  in  abscess 
cases  as  being  less  dangerous  than  immediate  work  and  leaving  the 
root  end. 

The  procedure  of  cutting  off  the  root  end  removes  a  necrotic  and 
often  septic  area  if  apical  abscess  was  the  reason  for  removal,  and 
while  the  present  thorough  aseptic  curettement  of  the  abscess  tract 
may  render  the  operation  of  immediate  replacement  safer  than 
formerly  the  writer  has  in  mind  an  unpublished  case  of  a  former 

^  Johnson's  Text  Book  of  Operative  Dentistry. 
2  See  Chapter  on  Asepsis. 


IMPLANTATION  779 

prominent  Philadelphia  dentist  whose  patient  died  as  the  result.  To 
be  sure  the  times  were  preaseptic.  The  condition  of  a  septic  alveolus 
seems  to  require  delay  if  only  for  the  purpose  of  reducing  the  sepsis. 
In  a  case  of  lateral  perforation  as  a  cause  the  root  end  is  not  removed. 
With  these  differences  of  view  conceded  the  other  procedm-es  are  the 
same. 

Fig.  716  •  Fig.  717 


Replantation  case  lost   after  about  two  Implantation  done  in  the  early  days 

months.  of  the  operation,  lost  after  about   two 

years. 

1.  Before  extraction  an  impression  is  taken  and  a  splint  con- 
structed and  kept  sterilized. 

2.  The  tooth  is  extracted  with  effort  to  avoid  cervical  injury  and 
placed  in  an  antiseptic  (and  with  the  apex  cut  off),  the  root  canal 
reamed,  sterilized  and  filled;  any  lateral  perforation  reamed  into  a 
cavity  with  parallel  edges  and  solidly  filled  with  amalgam  and  then 
polished.  The  tooth  is  again  put  into  the  solution  until  needed 
and  the  operation  performed  at  leisure. 

TRANSPLANTATION. 

This  is  also  an  old  operation.  It  does  not  differ  materially  from 
replantation  except  that  it  was  formerly  done  freshly,  septically,  and 
hence  could  be  a  cause  of  disease  by  transmission  or  by  ordinary 
sepsis.  At  present  the  difference  lies  in  the  fact  that  the  alveolus 
is  simply  made  to  fit  the  root  prepared  as  for  replantation.  Asepsis 
renders  the  question  of  disease  neghgible.  The  splint  would  be  made 
as  in  implantation. 

IMPLANTATION. 

An  impression  and  bite  are  taken  and  "  set  up."  A  hole  is  bored  in 
the  plaster  cast  where  the  alveolar  process  will  be  reamed  and  a  proper 
extracted  tooth  which  has  been  kept  in  alcohol  and  glycerin  is  selected 
and  its  root  prepared  as  for  replantation  except  that  the  apex  should 


780 


PLANTATION  OF  TEETH 


not  be  removed,  but  if  roughened  at  the  apex  may  be  smoothed.  In 
default  of  a  tooth  a  good  root  is  used  and  a  crowai  mounted  perfectly 
upon  it,  using  the  cast  and  bite  as  a  guide  to  occlusion,  fit  and  direc- 
tion of  root.  The  tooth  is  "tacked"  in  place  with  wax  or  plaster 
on  the  labial  side  and  the  splint  constructed  as  for  replantation. 
Tooth  and  splmt  are  placed  in  an  antiseptic  until  needed. 

At  operation  anesthesia  is  secured.  A  trephine  has  its  collar  set 
at  the  level  of  the  point  to  which  the  root  neck  enters  the  bone  while 
the  edge  of  the  trephine  is  just  short  of  the  root  apex  if  smaller 
than  the  trephine  at  it  if  larger.  The  bone  reamer  is  set  likewise, 
all  being  handled  aseptically.  (See  Figs.  718  and  720.)  The  area 
of  operation  is  isolated  and  thoroughly  asepticized.  With  a  surgical 
knife  a  mesiodistal  incision  is  made  just  lingual  to  the  center  of 


Fig.  718 


Fig.  719 


Fig.  720 


.u  u  tj  y 

12      3      4      5 


d-   ffli  |j4l  EH  lin 
^  ^  l|^  ffiii  sti 

1      ^%     iilJ    £p£|    ijjj 


1     2 


Younger- Walker  trephines.     Ottofy  spiral  crib  knife.       Ottolengui's  reamers. 

the  proposed  entrance  point,  a  second  buccolingually  at  right  angle 
to  it  is  made  distal  to  the  entrance  point  and  a  third  mesial  to 
it,  each  reaching  the  bone.  With  a  periosteal  elevator  the  gum  is 
dissected  up.  The  trephine  is  carefully  but  powerfully  driven  by 
the  engine  into  the  ah'eolar  bone  observing  the  intended  direction. 
^'Vhen  in  to  the  collar  the  bone  reamer  is  used  to  enlarge  the  socket. 
The  tooth  is  tried  in  and  the  socket  altered  as  needed.  The  trials 
and  alterations  are  continued  until  the  tooth  is  in  good  position  and 
preferably  quite  tight.  The  splint  is  tried  on  and  burnished  as  needed. 
All  being  ready,  the  tooth  is  dipped  in  phenol  sodique  1  to  6  and  the 
socket  washed  out.  A  little  blood  is  invited  and  the  tooth  put  in,  the 
parts  dried  and  the  splint  set.  The  splint  should  remain  about  eight 
weeks,  when  it  is  to  be  remo^'ed  and  the  attachment  tested.  Strict 
asepsis  and  prophylaxis  are  valuable  aids  to  success.    This  operation 


IMPLANTATION 


781 


is  only  indicated  for  a  single  anterior  tooth  when  there  is  sufficient 
alveolar  bone  and  when  it  is  preferred  by  both  operator  and  patient 
to  bridge  work. 


Fig.  721 


Fig.  722 


ri/tJcyT/^ 


t»» 


Fig.  723 


E»« 


Tubular  knife  for 
cutting  gum. 


Trephine  with  central 
starter  later  removed. 


Trephine  -n-ith  central 
starter  removed. 


Fig.  724 


Fig.  725 


Fig. 726 


Fig.  727 


Artificial  socket 
drilled  in  bone,  a 
core  being  left. 


Artificial  root  and 
crown  separated. 


Artificial  root 
with  crown  in 
place. 


Artificial  root  in 
place. 


If  the  operation  does  not  fail  practically  at  once  from  a  few  A'ears  to 
sixteen  years  may  be  hoped  for.  These  conditions  render  the  opera- 
tion infrequent  but  it  has  its  place  (Figs.  716  and  717).  If  sepsis 
occur  the  patient  may  complam  of  a  bad  taste.  This  will  probably 
be  due  to  a  loosenmg  of  the  splint. 

Greenfield^  has  introduced  an  artificial  root  made  cribriform  of 


1  Pental  Cosmos,  April,  1913. 


782  PLANTATION  OF  TEETH 

platinum  soldered  with  pure  gold.  Special  instruments  of  varied 
sizes  are  necessary  to  correspond  with  the  sizes  of  the  roots.  Under 
due  aseptic  precaution  the  gum  is  cut  with  a  tubular  knife,  and  the 
socket  drilled  with  a  circular  trephine,  which  preserves  a  core  of 
bone,  and  the  root  covered  with  Beck's  bismuth  paste  is  inserted. 
Later  a  crown  is  mounted  or  a  bridge  attachment  constructed. 
The  reader_^is  referred  to  the  article  for  details.  The  editor  has  had 
no  experience  with  this  method.  All  other  artificial  roots  are  said 
to  be  failures. 


CHAPTER  XXIX. 

THE  USES  OF  ELECTRICITY  IN  DENTAL 
THERAPEUTICS. 

Electricity  is  used  in  dentistry  in  one  of  the  following  ways, 
each  of  which  contributes  to  the  care  of  the  teeth  and  their  diseases, 
according  to  its  use: 

L  As  a  source  of  mechanical  power,  heat  or  light. 

2.  xAs  a  means  of  mechanical  or  electrical  vibration  of  tissue  or 
cells  or  possibly  as  a  chemical  alterative  to  cells. 

3.  As  a  means  of  introduction  of  medicaments  bodily  into  tissues 
(cataphoresis,  anaphoresis) . 

4.  As  a  means  of  electrolytic  decomposition  of  chemicals  for  the 
introduction  of  the  selected  ions  into  the  tissues. 

5.  As  an  agent  acting  in  place  of  an  anesthetic  by  substituting  a 
continuous  bearable  sensation. 

6.  As  a  method  of  testing  pulp  vitahty  or  death. 

7.  As  a  sterilizing  or  bleaching  agent. 

1.  Power. — The  uses  of  electricity  as  a  means  of  actuating  electric 
motors  which  either  directly  from  the  armature  shaft  or  by  means 
of  pulleys  and  cords,  drive  fans,  dental  engines,  lathes,  air  com- 
pressors, etc.,  is  so  familiar  that  one  need  but  mention  them.  These 
employ  either  of  the  commercial  currents,  the  direct  or  the  alternating, 
usually  in  their  full  voltage  and  connected  directly  to  the  apparatus 
from  the  electric  light  plugs  or  transmitted  through  special  full- 
voltage  connections  on  a  switchboard  where  they  are  conveniently 
controlled.  These  derive  power  through  the  alternate  making  and 
unmaking  of  temporary  magnets  which  attracts  the  armature  up 
to  a  certain  point  and  then  another  takes  up  the  work,  thus  rotary 
motion  is  obtained.  Power  is  also  obtained  by  the  use  of  the  prin- 
ciple of  attraction  of  a  hinged  armature  by  a  temporary  magnet. 
The  latter  consists  of  a  core  of  soft  iron  wound  with  insulated  wire 
through  which  current  passes,  when  the  circuit  is  completed  by  the 
contact  of  the  armature  at  the  time  it  is  separated  from  the  magnet 
by  a  spring  which  pushes  or  draws  it  back.  At  this  instant  the 
ciu-rent  passing  through  the  wire  induces  a  current  in  the  iron  core 
thus  making  it  a  magnet.    It  attracts  the  armature  (overcoming  the 

(783) 


784     USES  OF  ELECTRICITY  IN  DENTAL  THERAPEUTICS 

power  of  the  spring)  which  flies  toward  it  thus  breaking  the  electric 
connection.  The  magnet  loses  its  temporary  power,  the  spring 
forces  the  armature  back  again.  Electric  connection  is  renewed. 
Thus  vibratory  motion  is  produced. 

The  electric  telegraph,  telephone,  spring-battery  interrupters, 
electric  bells  and  other  devices  are  thus  operated  and  rotary  devices 
like  motors  are  but  a  modification  of  the  principle. 

Tlie  electric  mallet  uses  the  impulse  of  the  armature  when  attracted 
to  the  magnet  causing  it  to  strike  the  plugger  handle  or  corresponding 
device.  An  electrically  operated  vibrator  for  massage  or  therapeutic 
vibration  utilizes  the  power  of  the  armature  when  drawn  back  by  the 
recoil  of  the  spring  though  it  can  be  operated  as  in  the  electric  mallet. 

Heat.- — ^This  is  obtained  by  the  passage  of  current  through  wire 
which  by  its  resistance  to  the  current  becomes  heated  while  it  con- 
tinues to  conduct  current  because  its  melting-point  is  high.  When 
this  is  exceeded  the  instrument  ''burns  out."  The  cautery  is  used 
for  the  purpose  of  burning  or  carbonizing  tissue,  the  removal  of  which 
is  desired  (see  page  111).  The  root  drier  for  removing  moisture  from 
root  canals  and  dentin  has  its  point  heated  at  one  end  by  a  current 
heating  its  socket  in  a  manner  similar  to  the  cautery.  The  gutta- 
percha heater  carries  and  softens  gutta-percha  pellets  for  filling  pur- 
poses or  can  be  used  to  supply  heat  for  diagnostic  purposes  (see  page 
483).  The  hot  air  syringe  for  drying  about  cavities,  roots,  etc.,  even 
to  dessication  if  required  has  a  coil  of  wire  similarly  heated  and  over 
which  air  from  the  compressor  tank  passes. 

In  all  small  devices  platinum  wire  is  used  and  special  resistances 
are  supplied  on  the  switchboard  to  control  accurately  the  quantity 
of  current  in  order  to  prevent  "burning  out."  In  the  gold  annealer 
and  the  electric  oven  the  platiniun  wire  is  embedded  in  fire  clay 
which  it  raises  to  a  high  heat.  In  electric  water  heaters  or  electric 
sterilizers,  other  metals  as  German  silver  may  be  used  and  special 
replaceable  "fuses"  melting  at  lower  temperatures  are  usually  fur- 
nished as  safety  devices  to  protect  the  wiring. 

Light. — ^Light  is  required  as  in  the  ordinary  room  lighting  and 
oral  lighting  and  for  diagnostic  purposes  as  in  the  antrum  lamp  and 
dental  diagnostic  mouth  lamp  (see  page  302).  The  principle  involved 
is  the  passage  of  current  through  a  special  filament  (carbon,  tungsten, 
etc.),  in  a  vacuum  or  nitrogen  filled  glass  bulb  for  the  purpose  of 
preventing  access  of  oxj^gen  which  would  allow  immediate  destruc- 
tion of  the  filament.  It  is  a  question  of  heating  to  incandescence, 
thus  producing  light. 

Specially  colored  bulbs,  violet,  blue,  etc.,  as  well  as  white  are  con- 
sidered to  produce  chemical  effects  on  tissue  and  are  employed  in 


USES  OF  ELECTRICITY  IN  DENTAL  THERAPEUTICS     785 

general  therapeutics.  The  well-known  Finsen  light  is  so  arranged 
as  to  produce  a  cold  but  highly  chemic  white  light  useful  in  superficial 
diseases.  Aside  from  the  use  of  a  blue  light  as  a  possible  means  of 
inducing  an  analgesic  condition  for  operative  purposes  (see  page  526) ; 
or  its  application  to  painful  swellings  of  the  face  (or  joints  if  recom- 
mended by  a  physician)  colored  lights  have  little  application. 

The  heat  of  electric  light  globes  of  some  size  (100  candle  power) 
is  also  employed  by  means  of  a  parabolic  reflector  for  the  purpose 
of  activating  the  blood  and  lymph  circulation  which  is  usually  further 
stimulated  by  massage,  dry  cupping,  etc.  An  .r-ray  apparatus 
develops  ultra  violet  light  (yellowish  green  to  the  eye)  by  passage  of 
an  interrupted  electric  current  through  a  Crooke's  vacuum  tube.    ■ 

The  color  of  the  light  m  the  tube  depends  upon  the  degree  of  vacuum. 

The  chemic  quality  of  the  light  rays  passing  through  tissue  to  a 
photographic  plate  or  film  gives  it  its  value  in  diagnosis  while  its 
chemic  effects  are  utilized  in  therapeutics,  especially  in  superficial 
diseases  as  lupus  and  carcinoma.     (See  Radiography.) 

2.  Mechanical  vibration  is  applied  to  tissue  by  means  of  apparatus, 
deli^'ering  a  rapid  series  of  light  blows  as  the  applicator  (ball,  water- 
bag,  etc.)  is  passed  over  the  surface.  The  circulation  and  lymph 
flow  is  activated  and  stases  of  various  degrees  and  consequences 
relieved.    It  is  vibratory  massage  of  tissue. 

Electricity  is  not  an  essential  feature  of  vibratory  massage  and 
does  not  enter  the  tissues  being  massaged,  but  is  a  convenient  source 
of  power  for  a  mechanical  vibrator  (see  page  533). 

Electric  Vibratory  Massage. — A  certain  amount  of  contraction  of 
muscular  tissue  (including  those  of  bloodvessels)  may  be  induced 
by  the  ordinary  Faradic  current  which  consists  of  unidirectional,  low- 
voltage  electricity  frequently  interrupted.  With  infrequent  appli- 
cation or  interruption  a  marked  muscular  contraction  occurs  which 
may  be  utilized  to  stimulate  respiration  as  in  poisoning  or  drowning 
cases,  while  with  constant  contact  a  cell  and  muscular  agitation  is  pro- 
duced. The  passage  of  the  Faradic  current  has  been  experimentally 
shown  to  have  beneficial  eft'ects  on  the  general  nutrition  of  normal 
experimental  animals,  they  having  gained  weight  faster  than  the 
control  animals. 

As  each  dentist  should  possess  a  small  Faradic  apparatus  for 
diagnostic  purposes,  it  may  be  used  with  the  positive  pole  (sponge 
electrode)  passed  over  a  swoUen  face,  the  negative  in  the  hand.  The 
current  is  controHed  by  the  core  cover  (tube  of  Duchenne).  The 
application  should  in  this  case  be  continuous  and  the  characteristic 
tingling  sensation  is  to  be  expected.  This  treatment  is  known  as 
"Faradization."  (See  Fig.  477.) 
50 


786      USES  OF  ELECTRICITY  IN  DENTAL  THERAPEUTICS 

Electric  vibration  or  vibratory  massage  of  cells  is  supposed  to  be 
effected  by  the  so-called  "violet  ray"  apparatus. 

This  is  the  application  of  the  alternating  current  which  has  been 
"stepped  up"  by  special  transforming  devices  until  a  very  high 
degree  of  voltage  (intensity  of  cm-rent)  with  very  low  amperage 
(quantity  of  current)  is  attained.  The  current  no  sooner  flows  in  one 
direction  than  it  flows  back  in  the  other,  in  both  with  varying  intensity 
during  the  flows  which  is  the  characteristic  of  an  alternating  current 
and  is  called  "oscillation." 

Fig.  728 


Rogers  violet  ray  apparatus. 


The  alternations  (of  direction)  are  so  frequent  per  second  that  the 
current  is  properly  called  a  "high  frequency"  current.  In  such  high 
frequency  muscular  contraction  is  not  noted  as  it  is  in  lower  alterna- 
tions (below  10,000  cycles) .  As  it  passes  into  vacuum  tubes  of  varying 
shapes  (electrodes)  the  ether  therein  is  agitated  and  varying  colors 
are  produced  according  to  the  degree  of  vacuum  present.  In  dental 
apparatus  a  violet  color  is  developed,  hence  the  term  "violet  ray." 

There  is  no  need  for  two  electrodes  as  the  current  passes  in  and 
back  or  may  be  transmitted  via  the  body  to  another  similar  electrode 
actuating  it  also  to  violet  color.  Its  conduction  through  the  body 
may  be  assured  by  using  a  metal  conductor  (as  a  chair  arm,  etc.) 
on  the  opposite  side.  Glass  (or  the  enamel  of  teeth)  does  not  insulate 
it  and  even  rubber  will  transmit  it  at  points  opposite  the  electrode; 
also  it  penetrates  clothing  and  will  jump  ajair  air  space  and  actuate 
a  similar  electrode  held  near  it  even  if  the  spark  does  not  jump  the 
space.  In  practice  the  high  frequency  current  (alternating)  may  be 
developed  from  the  commercial  direct  current  by  special  transforming 


USES  OF  ELECTRICITY  IN  DENTAL  THERAPEUTICS     787 

devices  included  in  the  commercial  forms  of  apparatus,  so  that  it 
is  only  necessary  to  attach  to  the  ordinary  light  socket  or  switchboard 
(full  voltage).  A  certain  amount  of  ozone  is  produced  about  the 
electrode  by  the  chemical  change  in  the  oxygen  of  the  air  as  occurs 
about  a  Crookes's  tube.  The  electrical  agitation  is  supposed  to  effect 
great  activity  in  the  cells  increasing  metabolism  (chemical  change), 
also  to  stimulate  circulation.  It  is  used  for  this  purpose  in  pyorrhea 
alveolaris.    Possibly  ozonization  may  play  a  part  (see  page  685). 

It  is  also  an  analgesic  agent  and  has  been  employed  to  obtain 
access  to  parts  (as  third  molar  gums,  abscesses,  etc.,  when  patients 
are  imable  to  open  the  mouth.  For  this  the  use  of  the  broad  elec- 
trode for  twenty  minutes  on  the  face  oA^er  the  part  is  recommended. 
Vaselin  should  first  be  applied.  ^Vhile  its  use  in  dentistry  as  a  caustic 
is  not  known^  in  medicine  a  long,  sharp  spark  from  a  single  pointed 
special  electrode  (fulguration)  has  cauterant  properties  employed  on 
small  growths.  It  might  be  used  in  certain  cases  were  not  the  electric 
cautery  available. 

3-4.  The  introduction  of  drugs  into  tissue  by  means  of  a  galvanic 
current  has  long  been  known.  For  purposes  of  definition  a  primary 
current  from  a  battery  and  a  commercial  direct  current  (produced 
by  a  dynamo)  are  the  same  and  understood  as  galvanic  so  far  as 
therapeutics  is  concerned.  It  only  remains  to  reduce  the  110  volt 
direct  current  by  means  of  a  suitable  resistance  to  about  30  or  40 
volts.  From  that  point  on  a  special  resistance  (current  controller) 
is  used  either  with  the  direct  commercial  current  or  direct  battery 
current.  The  original  cataphoric  apparatus  introduced  by  Gillette 
was  actuated  by  a  battery  of  from  20  to  30  dry  cells,  silver  chlorid 
preferred,  but  Leclanche  cells  or  others  could  be  used.  This  developed 
the  electricity  which  was  taken  from  the  positive  pole  (carbon)  to 
the  special  resistance,  thence  to  a  milliamperemeter  (recording  the 
quantity  of  current  passing  in  spite  of  the  resistance  of  the  patient, 
plus  the  special  resistance),  thence  to  the  tooth  cavity  (in  which  a 
solution  of  cocain  hydrochlorid  was  placed  on  cotton  and  under  the 
positiA'e  electrode),  thence  via  the  pulp,  patient's  tissues,  to  the  arm 
and  hand  to  the  negative  electrode  and  back  to  the  negative  (zinc) 
pole  of  the  battery  thus  establishing  a  dhect  current  circuit. 

In  its  passage  from  positi"S'e  to  negative  certain  substances  as 
cocain  are  carried  bodily  with  the  current  apparently  intact  (cata- 
phoresis).  If  the  current  carries  an  electronegative  substance  such 
as  iodin  intact  from  the  negative  toward  the  positiA'e  pole  it  is  called 
anaphoresis. 

If  the  current  decomposes  a  chemical  compound  into  its  constit- 
uent parts  (or  ions)  the  ions  which  are  naturally  electropositively 
charged  travel  to  the  negative  pole  (cations),  while  the  other  ions 


788      USES  OF  ELECTRICITY  IN  DENTAL  THERAPEUTICS 

naturally  electronegatively  charged  t^a^'el  toward  the  positive  pole 
(anions).  This  is  electrolysis  (or  electrolytic  dissociation)  and  its  use 
m  therapeutics  is  termed  electrolytic  medication.  The  term  ions  refers 
to  the  electropositively  charged  or  electronegatively  charged  particles 
in  a  molecule.  They  are  set  free  by  electrolysis  and  are  the  conductors 
of  electricity.  Thus  m  electrolysis  of  water  H  being  positive  conducts 
the  positive  current  flow  and  is  attracted  to  the  negative  pole  (cation) 
while  O  being  electronegatiA'e  carries  the  negative  current  flow  in  the 
opposite  direction  to  the  positive  pole  (anion) . 

Custer^  illustrates  these  opposite  current  flows  by  a  stream  of 
wagons  crossing  a  bridge  in  one  direction  carrying  one  kind  of  mer- 
chandise while  another  stream  crossing  in  the  opposite  direction  carry 
merchandise  of  another  kind. 

Stiuridge-  objects  to  the  terms  cataphoresis  and  anaphoresis  as 
here  defined,  claiming  that  probably  in  aU  cases  an  ionic  effect  is 
produced.  He  does  not  say  an  electrolytic  production  of  ions,  but 
a  carrying  of  cocain  ions,  for  example,  as  a  fraction  of  a  molecule 
into  the  pulp  tissue.  He  also  says:  "It  is  quite  conceivable  that 
a  substance  like  cocain  when  acted  upon  by  water  is  split  up 
into  ions  and  in  this  state  is  readily  introduced,  etc."  Again 
he  states  that  Leduc  introduced  strychnin  into  a  rabbit's  ear  by 
passing  a  cm-rent  with  positive  at  the  ear.  The  animal  died  in 
t^•pical  strychnin  con\Tilsions. 

He  cites  other  cases  of  actual  transference  of  substances  into  tissue 
as  alarming  cocain  poisoning  from  application  with  the  cataphoric 
current  positive  pole  at  tooth  pulp.  Considering  the  complex  nature 
of  cocain  and  strychnin  and  that  electrolysis  e\idently  did  not  occur 
otherwise  the  strychnin  and  cocain  would  have  been  dissociated 
into  their  ions  and  could  not  have  produced  their  characteristic  effects, 
it  seems  rational  to  admit  the  term  cataphoresis  at  least.  As  ana- 
phoresis x)ccurs  against  the  general  current  flow  (from  negative  to 
positive)  it  must  be  defined  as  an  anodic  travel  of  negatively  charged 
ions;  that  is,  the  chemically  unbroken  substance  is  an  anion. 

In  electrolysis  the  following  elements  of  a  molecule  arrange  them- 
selves into  then-  respective  electric  group,  becoming  anions  or  cations 
as  may  be: 

Electropositive  or  Cations.  Electronegative  or  Anions. 

Copper.  Arsenic. 

Iron.                              ■  Bromine. 

Hydrogen.  Chlorine. 

Mercury.  lodin. 

Potassium.  Nitrogen. 

Sodium.  Oxygen. 

Zinc.  Sulphur. 

All  basic  radicals.  All  acid  radicals. 

1  Dental  Electricity.  ^  Dental  Electo  Therapeutics. 


USES  OF  ELECTRICITY  IN  DENTAL  THERAPEUTICS     789 

In  order  to  obtain  penetration  of  the  cations  from  their  salts  hi 
sohition  the  positive  pole  must  be  applied  to  the  point  from  which 
they  are  to  be  diiven  and  the  negative  pole  on  the  side  they  are  to  be 
delivered ;  for  example,  to  reach  apical  tissue,  the  tooth  root  and  the 
hand  respectively.    For  the  anions  the  poles  are  reversed. 

The  ions  available  for  such  therapeutic  purposes  as  sedation, 
stimulation,  disinfection  and  comiter-irritation  are  ably  suggested 
by  Stiu-ridge,  Prinz  and  others. 

Zinc  ions  may  be  de^'eloped  and  driven  in  by  the  use  of  a  3  to  5 
per  cent,  zinc  chlorid  aqueous  solution,  a  positive  zinc,  platinum  or 
steel  electrode  and  2  to  3  m.a.  of  current,  the  negative  being  at  the 
hand,  etc.  It  is  considered  antiseptic  and  useful  in  apical  suppiu-ation 
or  pyorrhea. 

Copper  ions  may  be  dissociated  by  the  use  of  3  per  cent,  aqueous 
copper  sulphate  solution,  a  positive  copper  electrode  and  1  or  2  m.  a. 
Negative  pole  at  the  hand.  A  copper  spatula  may  be  used  in  the 
gingival  trough  and  a  copper  probe  in  a  fistula  in  like  manner. 

Silver  ions  are  obtained  by  the  use  of  weak  aqueous  silver  nitrate 
and  a  positive  silver  electrode.  lodin  ions,  a  weak  aqueous  solution 
of  the  tincture  of  iodin  is  used  with  a  negative  platinum  electrode, 
positive  at  the  hand  as  it  is  electronegative.  It  is  used  for  disinfecting 
and  healing  apical  tissues  or  to  be  driven  into  the  gum  surface  over 
the  apex  in  case  of  apical  pericementitis.  Chlorine  ions  are  developed 
in  like  manner  from  1  per  cent,  aqueous  sodium  chlorid  solution,  if 
penetration  of  apical  tissue  is  desired.  Prinz^  suggests  the  positive 
in  the  canal  for  canal  sterilization,  using  a  constant  (30)  as  a  means 
of  calculation  of  the  time  of  application  required  according  to  the 
formula: 

30 

Time  (for  example  here  10  minutes). 


m.  a.  (for  ex:ample  3  m.  a.) 


Oxygen  ions  may  be  obtained  from  the  loosely  held  O  of  H2O2  by 
the  use  of  a  negative  platinum  electrode  in  the  tooth,  positive  at  the 
hand.  The  ordinary  use  of  H2O2  is  with  the  positive  at  tooth  (cata- 
phoresis)  but  occasionally  the  reversal  of  the  poles  is  valuable  in 
bleaching  (see  page  507). 

The  salicylic  ion  is  dissociated  from  salicylate  of  soda  solution  on 
cotton  by  a  broad  positive  electrode  (1|  inch  square)  placed  over 
site  of  neuralgia  and  a  5  inch  square  negative  electrode  over  upper 
cervical  vertebrae.    (Sturridge.) 

Sturridge  also  commends  a  solution  of  argyrol  as  sedative  and 

1  Dental  Cosmos,  April,  1917. 


790      USES  OF  ELECTRICITY  IN  DENTAL   THERAPEUTICS 

healing  in  acute  gingi^atis  or  sloughing  giun,  positi^•e  j^Iatiniun  or 
silver  electrode  at  gums,  with  doubt  as  to  ionic  effects. 

The  cocain  ion  has  been  considered  under  cataphoresis. 

The  advantages  of  electrolytic  medication  are  the  production  of 
nascent  ions  and  their  introduction  into  the  tissues  as  against  mere 
superficial  contact. 

Technic- — ^With  the  exception  of  application  external  to  the  tooth 
as  in  pyorrhea  the  rubber  dam  is  to  be  adjusted  for  insulation  in 
dentin  and  pulp  work  and  for  asepsis  in  canal  work.  Any  external 
asepsis  needed  is  to  have  attention.  In  either  cocain  cataphoresis  or 
canal  work  amperage  is  important  and  is  governed  by  the  sensation 
of  the  patient. 

In  case  of  commercial  current  a  "grounding"  of  the  circuit  is  to  be 
avoided  by  the  use  of  a  rubber  mat  under  the  chair  and  avoidance  of 
metal  parts  of  the  chair  or  cuspidor  by  the  patient.  INIetal  rings,  etc., 
are  to  be  removed  to  prevent  blistering.  The  apparatus  is  set  with  the 
volt  selector  (rheostat  or  resistance)  at  zero,  the  wrist  pad  or  metal 
electrode  of  ample  dimensions  to  prevent  a  blister  is  moistened  with 
salt  solution  and  adjusted  to  or  in  the  left  hand,  the  proper  pole  being 
observed.  The  medicament  being  used  is  applied  and  a  proper 
electrode  applied  to  the  tooth.  The  current  is  now  slowly  turned  in 
and  as  pain  is  felt  the  indicator  of  the  current  controller  is  turned 
back  a  little  then  advanced  again  until  full  toleration  is  obtained. 
In  the  case  of  cocain  anesthesia  the  lack  of  response  to  a  slight 
jump  of  the  current  indicates  pulp  anesthesia  and  one  may  operate 
at  least  on  the  dentin.  The  milliamperemeter  will  indicate  the 
amount  of  current  flowing  against  the  resistance.  This  is  only  of 
^'alue  as  showing  that  electricity  is  passing  (and  for  scientific  statistics) 
in  cocain  cataphoresis,  as  toleration  is  the  essential  point.  The  instru- 
ment may  even  be  dispensed  with.  It  has  value  in  root  sterilization, 
however.  (For  details  of  this  see  page  496.)  ^Yhen  through,  the 
indicator  of  the  controller  is  gradually  turned  back  to  zero,  thus 
turning  in  the  resistance;  the  electrodes  are  then  removed. 

The  high  frequency  current  has  also  been  suggested  as  a  cata- 
phoric agent  in  hypersensitive  dentin.  A  pointed  electrode  and  a 
very  mild  current  is  used  against  a  crystal  of  carbolic  acid  placed  in 
the  cavity  for  from  a  half-minute  to  a  minute  or  if  still  sensitive  a 
half  minute  longer  (Hubbel^) .  Placing  a  crystal  of  novocain  in  the 
cavity,  dipping  the  electrode  in  adrenalin  solution  and  applying 
with  a  very  mild  current  is  also  recommended  by  Hubbel  for  hyper- 
sensitive dentin  and  to  get  an  exposure  of  the  pulp. 

1  Quoted  by  Eberhart:  High  Frequency  Manual. 


USES  OF  ELECTRICITY  IN  DENTAL  THERAPEUTICS     791 

He  also  uses  it  as  a  cataphoric  agent  for  driving  bleaching  solutions 
in  bleaching  teeth,  the  apical  region  to  be  previously  filled. 
Its  value  in  sterilizing  root  canals  is  yet  indeterminate. 

5.  While  not  an  anesthetic  agent  in  itself  a  mild  induced  inter- 
rupted current  has  been  used  as  a  means  of  substituting  a  steady 
impulse  or  sensation  along  the  nerve  trunk  which  confuses  the  center 
of  pain  perception.  The  method  at  least  in  its  refinement  was  intro- 
duced by  J.  Foster  Flagg  who  used  what  he  termed  a  Dental  Helix. 
There  was  but  one  coil  conveying  the  primary  current  which  was 
interrupted  in  its  course.  The  current  was  strengthened  by  an  induc- 
tion core  consisting  of  a  bundle  of  wires.  This  was  covered  by 
a  tube  of  Duchenne  which  could  be  drawm  off  the  core.  A  water 
rheostat  was  used  to  reduce  the  current  to  the  most  delicate  possible. 
The  positive  electrode  was  bayonet-shaped  and  of  strong  wire  covered 
by  hard  rubber.  A  cup  applicator  at  the  end  held  a  bit  of  wet  sponge 
to  be  pressed  against  the  gum  above  the  tooth.  The  negative  elec- 
trode was  the  metal  casing  of  the  handle  of  the  same  electrode  and 
made  the  contact  with  the  hands.  The  current  therefore  passed 
through  the  gum  to  the  arm  and  hand  holding  the  applicator.  This 
instrument  was  satisfactory  in  some  cases,  the  chief  difficulty  lying 
in  the  fact  that  it  was  apt  to  shp  causing  a  shock  or  be  in  the  way. 
It  may  be  that  a  modified  applicator  may  render  it  of  more  utility. 
In  extraction  the  positive  pole  of  the  helix  was  attached  to  the  forceps 
by  special  cords,  the  negative  placed  in  the  hands  and  was  said  to 
give  some  satisfaction. 

6.  Any  mild  interrupted  current  capable  of  increase  or  a  mild 
high  frequency  current  may  be  used  as  a  means  of  diagnosis  of  pulp 
vitality.  A  small  Faradic  battery  energized  by  a  single  dry  cell  is 
sufficient  for  a  current  too  strong  for  application.  A  rheostat  elec- 
trode is  described  on  page  486  by  means  of  which  a  very  delicate 
current  may  be  obtained  so  that  if  desired  a  filling  may  be  touched. 
Ordinarily  the  platinum  point  is  wound  with  cotton  wet  with  normal 
salt  solution  and  the  enamel  of  each  tooth  suspected  touched.  The 
strength  of  ciu-rent  is  first  determined  by  trial  on  a  soimd  tooth. 
Either  pole  may  be  used,  the  other  being  in  the  hand.  A  positive 
response  indicates  vitality,  but  no  response  to  a  strong  current  does 
not  of  necessity  mdicate  death.  Even  a  filling  or  the  bare  dentin 
may  occasionally  fail  to  conduct  so  as  to  produce  response  while 
on  drilling  sensitivity  may  be  obtained,  but  taken  altogether  it  is  a 
satisfactory  means  of  testing,  especially  if  taken  along  with  other 
tests  or  indications.  The  details  and  comparison  with  other  tests 
are  given  on  page  483. 

The  high  frequency  current  is  of  value,  also  as  an  electrical  test 


792      USES  OF  ELECTRICITY  IN  DENTAL  THERAPEUTICS 

when  applied  to  the  enamel,  though  even  with  this  remarkable  differ- 
ences of  response  in  apparently  normal  teeth  appear.  In  posterior 
teeth  the  sparks  tend  to  jump  to  the  cheek  rendering  it  necessary  to 
use  great  care.    One  should  always  use  mild  applications  at  first. 

7.  As  a  sterilizing  agent  electricity  has  been  written  of  both  as 
an  efficient  agent  and  as  failing  in  that  respect.  Usually  it  is  employed 
as  previously  described  as  a  cataphoric,  anaphoric  or  electrolytic 
force.  As  an  aid  in  bleaching  it  has  been  employed  as  described  on 
pages  507  and  789. 


INDEX. 


Abnormal  food  supply,  18 

nerve  supply,  18 

physical  conditions,  18 

waste  removal,  18 
Abrasion,  199 

acids  in,  207 

in  animals,  208 

of  calculus,  205 

degrees  of,  201 

during  sleep,  201,  213 

effects  of,  209 

from  clasp,  207 

gritty  powders  as  cause  of,  207 

labial  and  approximal,  203,  207 

lingual,  203,  205 

occlusal,  200 

pulp  hyperemia  in,  210 

relation  to  caries  in,  209 

tooth-brush  in,  203,  206 

treatment  of,  210 
Abscess,  apical,  acute,  512 

after  treatment  of,  534 
causes  of,  514 
cUnical  history  of,  520 
diagnosis  of,  523 
extraction  in,  529 
guards  in,  527 
necrosis  from,  530 
on  opening  teeth,  504 
pathology  of,  515 
radiography  in,  538 
scar  threatened  in,  533 
stages  of  pus  formation  in, 

516 
symptoms  of,  515 
systematic    stopping    in, 

540 
systemic  complication  in, 
519,  522,  529,  530,  532, 
534,    554.     {See   Infec- 
tion.) 
treatment  of,  525 
chronic,  520,  535 
bUnd,  555 

discharging  via  canal,  535 
grades  of,  535 
necrosis  from,  563 
not  healing,  548 
radiography  in,  538 
scar  from,  554 


Abscess,  apical,  chronic,  symptoms  of, 
538 
systemic  compUcations  in, 

557.     {See  Infection.) 
in  temporary  teeth,  566 
treatment  of,  539,  545 
varieties  of,  535 
with  fistula,  541,  544 
around  third  molar,  109 
perforation  of  bone  in,  528 
pericemental,  698 
pointing  in,  43,  518 
of  pulp,  410 
syringe,  546 
Absence  of  teeth,  192 
Absorbent  organ,  91 
Acacia,  use  of,  78 
Accidents  to  teeth,  599 
Acetanihd  as  cause  of  hemorrhage,  30 

use  of,  405,  532 
Acid,  extraneous  effect  of,  220 

fruits,  use  and  effects  of,  87, 220, 336 
neutrahzation  of,  223,  262,  284,  336, 
344,  455,  757,  759 
Acidosis,  622 

Aconite,  tincture  of,  109,  391,  527,  572 
Aconitin,  use  of,  109 
Actinomycosis  of  mouth,  734 
Adenoids  in  mouth  breathing,  97,  102 
Adrenalin,  use  of,  326,  430,  503 
Age  as  predisposition,  267 
Agenesia  of  enamel,  166 
Air,  compressed,  use  of,  323,  504,  800 

use  of,  323,  548 
Alcohol,  injection  of,  718 

use  of,  77,  131,  323,  332,  344,  391, 
396,  467,  532,  613,  629,  800 
Alcresta  ipecac,  use  of,  689 
AHmentary  canal  infection,  745.     {See 

Dentition.) 
Almond,  bitter  oil  of,  use  of,  336 
Aloin  compoimd,  use  of,  624 
Alopecia  from  dental  disease,  716 
Alum,  use  of,  31,  77,  396,  405,  420,  476, 

477,  482 
Alveolar  process,  fracture  of,  600 
AlveoUtis,  postextraction,  601 
Amalgam,  copper,  use  of,  351 

facing,  442 
Ameba  of  pyorrhea,  653 
Ameloblasts,  141 
Ammonia,  use  of,  334,  344,  431 
(803) 


804 


INDEX 


Ammonium  bifluorid,  use  of,  682 
Ammonol,  use  of,  314 
Amputation  of  roots,  771,  776 
Amj^l  nitrite,  use  of,  433 
Analgesia,  312,  526 
Anaphoresis,  496 
Anemia,  22,  24,  33,  268,  549 
Anesthesia  of  apical  tissue,  314,  etc. 

cataphoric,  328 

conductive,  314,  404,  428 

diploeic,  112,  322 

by  electric  current,  791 

general,  use  of,  312,  428 

infiltration,  321 

mucous,  321 

of  nerve  trunk,  428 

pressure,  429,  431 

of  pulp,  429 

reflex,  322 
Angina,  Ludwig's,  110,  739 

simplex,  739 

Vincent's,  608,  615,  740 
Angle,  classification  of  malocclusion  by, 

98 
Anise,  oil  of,  use  of,  336 
Ankylosis,  dental,  579 
Anomalies  of  teeth.    See  Malformations . 
Antacids.    See  Acid  Neutralization.) 
Antikamnia,  use  of,  314 
Antipyrin,  use  of,  717 
Antiseptic  powders,  antiseptic  washes 

and,  use  of,  78,  613,  755,  801 
Antiseptics,  use  of,  78 
Antitoxin  streptococcus,  use  of,  1 12,  532 
Antnma,  empyema  of,  542,  550,  717 
Aphasia  from  pulp  disease,  403 
Aphthae,  724 

Apicoectomv,   475,   549,  550,  554,  556, 
578  ' 

chapter  on,  771 
Aqua  regia,  use  of,  465 
Aristol,  vise  of,  344,  349,  350,  467,  469, 

478 
Arsenic,  accidents  with,  443 

action  of,  on  gum  tissue,  443 
on  pulp  tissue,  435 
variations  in,  437 

apical  hyperemia  from,  435-437 

formulae  for,  439 

iodide  of,  use  of,  400 

mummifying  paste  and,  445 

necrosis  from,  444 

objections  to,  438 

pentoxid,  use  of,  440 

pocket  for,  443 

preparations,  use  of,  616 

pulp  hyperemia  from,  435 

in  pulp  nodule,  375,  376 

resistance  to,  375,  437,  440 

seals  for,  441 

siiffusion  from,  438 

use  of,  335,  400,  405,  410,  435 
danger  of,  443 
Arsenical  fiber,  404,  430,  441 


Asepsis,  315,  448,  503,  793 

test  for,  503 
Aspirin,  use  of,  405 
Astringents,  use  of,  30,  78,  609 
Atomizer,  use  of,  804 
Atrophy,  33,  60,  159 

marginal,  of  gum,  625 

Harlan's  method  in,  626 
Atropin,  use  of,  574 
Attachment  of  teeth,  172,  175,  602    _ 
Auto-intoxication,  general  malnutrition 
as  cause  of,  618,  745 

oral,  effects  of,  619 

B 

Bacteria  of  blind  abscess  or  granuloma, 
555 

in  blood.     See  Septicemia. 

as  cause  of  inflammation,  30,  41-47, 
398,  415 

chromogenic,  237 

conditions  antagonizing,  18 

culture  test,  540 

of  dental  caries.     See  Caries. 

increased  virulence  in,  504 

hfe  of,  conditions  of,  18 

penetration  of  root  tubules  by,  567 
of  secondary  dentin  by,  368 

plaques  of,  244,  273 

of  putrefaction  of  pulp,  488 

pyogenic,  42,  512,  513 

spreading  of,  in  tissue,  519 
Balsam  of  Peru,  use  of,  682,  704 

of  Tolu,  use  of,  131 
Band,  dental.  Fig.  118 
Bandage,  use  of,  30 
Baths,  use  of,  625 
Belladonna,  use  of,  214 
Benzoic  acid,  use  of,  615 
Benzoin,  use  of,  131,  396,  404 
Bier's  hyperemia,  use  of,  626,  685 
Bilein,  use  of,  625 
Biliousness,  745 
Bismuth   preparations,  use  of,  79,  467, 

684 
Black,  glands  of,  556 
Black's  1-2-3  mixtm-e,  use  of,  683 

operation  for  scar,  554 
Bleaching  agents,  use  of,  238,  239,  506 
Blindness,  dental  cause  of,  580 
Blood,  alterations  in,  21 

bacteria  in.     See  Septicemia. 

coagulation  of,  24 

extravasation  of,  28,  38 

stasis  of,  38 
Blue  Kght,  use  of,  526 
Bodkin,  wire,  use  of,  754 
Bone,  caries  of,  51,  544 

of  face,  embryology  of,  133 

infection  of,  from  dental  lesions,  563 

inflammation  of,  48 

of  jaw,  development  of,  56 

necrosis  of,  50 


INDEX 


805 


Bone,  necrosis  of,   from   alveolodental 
a,scess,  553,  563 
from  sj^philis,  554 

perforation  of,  in  abscess,  528 

regeneration  of,  56 

resorption  of,  50,  587,  590,  623 
in  gingivitis,  623 
Borax.    See  Sodium  biborate. 
Boric  acid,  use  of,  570,  614,  717 
Boroglycerin,  use  of,  613 
Brandjf,  use  of,  77 
Bridge  work,  use  of,  589,  592 
Broaches,  Downie-Kerr,  use  of,  452,  500 

Swiss,  460 

use  of,  452,  460 
Bromides,  use  of,  313 
Bromural,  use  of,  313,  405,  528 
Brownin,  156 

Brush,  use  of,  203,  628,  751,  754 
Bruxomania,  201 


Caffein,  use  of,  532 
Cajuput  oil,  use  of,  500 
Calcareous  infiltration,  62,  377 
Calciiic  degeneration  of  pulp,  377 
Calcification  of  teeth,  141 

tubular,  360 
Calcium  chloride,  use  of,  31 
lactate,  use  of,  31 
salts  in  blood,  633 
in  pus,  647 
CalcoglobuHn,  365,  371,  383 
Calcospherites  in  dentin,  141 
in  enamel,  141 
in  pulp  nodiile,  371 
Calcuh,  basis  of,  62,  629 
Calculus,  analysis  of,  630 
hematogenic,  647 
origin  of,  629,  632 
pj^ogenic,  628,  647 
sahvary,  628 

analysis  of,  630 
Black's  experiments  on,  632 
foreign  bodies  in,  630 
hardening  of,  633 
hematogenic,  628 
mode  of  deposit  of,  633,  649 
occurrence  of,  636 
organic  factor  of,  632 
pathological  effects  of,  636 
pyogenic,  544,  556,  628 
removal  of,  638 
scalers  for,  639 
structure  of,  630,  632 
treatment  of,  638 
varieties  of,  629 
sanguinary,  628,  647 
sermnal,  628 
subgingival,  628,  644 
Calendula,  use  of,  615 
Callahan  methods,  448,  452,  469 


Callahan's  resin,  use  of,  455,  469 
Calomel,  use  of,  223,  624,  723,  730 
Campho-phenique.  See  Phenol  camphor. 
Canada  balsam,  use  of,  344 
Canals,  accidents  in  opening,  464 
continuity  of,  lost,  464 
filling  of,  466,  479,  534 

possibility  of,  467,  475 
fillings,  removal  of,  500 
imperfectlj'  fUled,  results  of,  475 
inoperable  apices,  475 
pastes  in,  476 
root,  enlargement  of,  448,  452 

topography  of,  452,  456 
in  temporary  teeth,  479 
Cancrum  oris,  725 
Cantharides,  use  of,  447 
Cantilever  wire  spur,  use  of,  611 
Capping  for  pulp,  348 
Capsicum  and  mjnrh,  use  of,  106 

plaster,  use  of,  528 
Carbohydrates  in  dental  caries,  253,  255 
Carbolic  acid,  use  of,  78,  110,  131,  420, 

433,  446,  528,  548,  572,  683 
Carbon  dioxid,  defective  ehmination  of, 
217 
paper,  use  of,  594 
Caries  of  bone,  48,  544 
dental,  241 

acid  medicines  in,  262 

milk  in,  255 
acids  in,  247,  248,  255,  262, 269 
neutraHzation  of,  259,  264 
age  in,  267 
alkalies  in,  255 
anemia  and,  268 
arrangement  of  teeth  in,  260 
backward,  278,  286,  296,  298 
bacteria  of,  248,  249,  250,  253, 

287,  288 
bacterial  plaque  in,  244,  245, 

253,  269,  274 
bodilj"  condition  in,  268 
bottle  feeding  in,  266 
calcareous  waters  in,  262,  267 
carbohydrate  fermentation  in, 

253 
causes  of,  exciting,  241 

predisposing,  local,  258 
systemic,  265,  277 
cavity  production  in,  284 
in  cementum,  259,  293,  298 
chemical  reactions  in,  254,  284 
clinical  history  of,  294 
color  of  teeth  in,  261 
debility  in,  268 
deep-seated,  337,  339 
defects  of  fillings  in,  260 
dentin  in,  280 

decalcification  of,  280 
destruction  of,  283,  284 
secondary,  297 
diabetes  and,  268,  269,  270 
diagnosis  of,  301 


806 


INDEX 


Caries,  dental,  diet  in,  253 
dj'spepsia  in,  268 
eburnation  in,  292 
electrical  theory  of,  242 
in  enamel,  273 

experiments  in,  245,  262,  266 
ferments  in,  245 
filth  as  a  protection  from,  271 
foodstuffs  in,  244,  245.  253,  255 
form  in,  258,  273,  275 
general  theory  of,  244,  257 
glucose  and,  254,  270 
glycogen  in,  265,  268,  269,  284 
gum  exudate  in,  259 
hard  and  soft  teeth  in,  262 
heredity  in,  266 
history  of,  241 

clinical,  294 
hj'persensitive  dentin  in,  304. 

See  Hj^persensitive  dentin, 
inception  of,  244,  257,  273,  294 
interglobular  spaces  in,  287 
lactates  formed  in,  284 
lactic  acid  in,  247 
leukemia  and,  268 
Uquefaction  foci  in,  285 
loss  of  crown  by,  352 

of  root  by,  353 

canal   continuity   in, 
353 

of  tissues  in,  289 
mentaUty  and,  300 
Miller's    general    experiments 

on,  245 
morbid  anatomy  of,  273 
mucin  in,  244,  263,  269 
of  Nasmyth's  membrane,  279 
nervous  exhaustion  in,  268 
oral  hygiene  in,  258,  268 
pathology  of,  273 
penetrating,  297 
perforation  bv,  298,  350 
periodicity  in,  267,  298 
pigmentation  in,  293 
pregnancy  and,  263,  268 
prenatal  influence  in,  266 
prognosis  of,  304 
progress  of,  274,  295 

saUva  in,  263,  264 
projjhylaxis  of,  268,  272,  358, 

747 
pulp  in,  almost  exposed,  342 

exposed,  303.  346 
recurrence  of,  357 
relatiA'e  liability  of  teeth  to,275 
retention  of  form  in,  295 
roughness  of  teeth  in,  261 
saUva  in,  263,  269,  270 
school  children  and,  268,  300 
secondary,  278,  286,  296,  298 

of  dentin,  297 
simple,  339 
spreading,  297 
stages  of,  337 


Caries,  dental,  strengthening  of  root  in, 
354 
structure  of  teeth  in,  261 
sugar  in  blood  and,  270 
sulphocyanate  in,  269,  270 
superficial,  337 
symmetr}'  of,  260 
symptoms  of,  301 
systemic  effects  of,  299 
of  temporary  teeth,  354 
terminations  of,  298 
therapeutics  of,  271,  337 
transparent  zone  in,  290 
tube  casts  in,  289 
tubules  in,  281 
typhoid  and,  268 
imder  fillings  in,  288 
water  and,  262,  267 
xerostoma  and,  264 
Caseation,  58,  556,  718 
Castor  oil,  use  of,  78 
Cataphoresis,  use  of,  327,  391,  433,  496, 

787 
Cataplasma  kaoHni,  use  of,  112,  532 
Cathartics,  use  of,  78,  85,  527 
Caush,  tubes  of,  in  enamel,  145,  261 
Caustics,  use  of,  331 
Cautery,  actual,  use  of,  335 

electric,  use  of,  351 
Cavitine,  use  of,  340,  342,  344 
Cells,  causes  of  disease  in,  18 
giant.  Figs.  17,  24,  45,  202 
hfe  conditions  of,  18 
phagocytic,  495 
stimulation  of,  effects  of,  19 
Celluhtis,  forms  of,  532,  739 
Cement  substance,  141 
solution  of,  275 
oxychlorid  of  zinc.     See  Zinc, 
oxy-eugenol,  345.   See  also  Zinc  and 

Eugenol. 
oxyphosphate  of  copper.     See  Cop- 
per, 
oxysulphate  of  zinc.     See  Zinc. 
silicate,  use^of.     See  SiUcate. 
zinc  phosphate.     See  Zinc. 
Cemental  nodule,  184 
Cementum  in  dental  caries,  259,  293, 
298 
formation  of,  93,  143 
histology  of.  Figs.  128,  134 
malformations  of,  microscopic,  154 
nutritional  relation  to  dentin,  145, 

Figs.  126,  128 
relation  of,  to  enamel,  145,  Fig.  144 
repair  of,  229 
Chalk  mixture,  use  of,  79 
use  of,  223,  335,  336 
Chancre  of  hands,  730 

of  mouth,  729 
Cheek,  distention  of,  by  air  pressure, 
504 
swelling  of,  109,  519,  526,  531,  533 
Chemotaxis,  41 


INDEX 


807 


Chewing  gum,  use  of,  757 

Chlorazen,  use  of,  493 

Chloral,  use  of,  84,  313 

Chlorin,  use  of,  496,  508 

Chloroform,  use  of,  85,   109,  312,  325, 

332,  335,  357,  391,  404,  409,  500 
Cliloro-percha,  use  of,  344,  467 
Chlorophyll,  235 
Chlorosis,  23 
Cholesterin,  556,  629 
Chorea  from  dental  disease,  578 

from  dentition,  107 
Chromic  acid,  use  of,  615 
Chromogenic  bacteria,  237 
Cinchona,  use  of,  131 
Cinnamon,  oil  of,  use  of,  131,  336,  614, 

627,  683 
Circulation,  disturbances  of,  33 
Clasps,  use  of,  591 
Cleansing  of  teeth,  237,  638,  748 
Cleft  palate,  embryology  of,  133 
Clot,  absorption  of,  28,  38,  56 

heahng  under,  56 

septic,  27,  28 
Cloudy  sweULng,  58 
Cloves,  oil  of,  use  of,  323,  335,  344,  391, 

420,  614 
Coagiilants,  use  of,  30 
Coagulation  of  blood,  24,  38 

necrosis,  52 
Cobalt,  use  of,  440,  441 
Cocain,  systemic  effects  of,  433 

use  of,  326,  327,  328,  331,  391,  429, 
431,  433,  438 
Codein,  use  of,  405 
Coffee,  use  of,  433 
Cold,  as  a  test,  484 

use  of,  527,  532,  570,  616 
CoUoid  degeneration,  59,  427 
Coloboma,  138 
Colophony,  use  of,  335,  469 
Combination  filhngs,  use  of,  343,  352, 

356 
Compress,  use  of,  30,  112,  533 
Concrescence  of  teeth,  171 
Conical  teeth,  168,  197 
Constipation,  dental  pain  from,  717 
Contacts,  approximal,  341,  355 
Convulsions,  cause  of,  74 
Copper  amalgam,  use  of,  346,  479 

cones,  use  of,  468 

ions,  use  of,  496 

oxyphosphate  of,  use  of,  107,  335, 
338,  345,  346,  352,  355,  356,  479, 
750 

sulphate,  use  of,  344 
Cord,  dental.  Fig.  118 
Cotton  root  dressings,  460,  491,  500 

tampons,  danger  of,  530,  564 
Counterirritants,  use  of,  391,  504,  572 
Counterpressure,  method  of,  525 

in  opening  tooth,  525 
Cresol,  use  of.     See  Formocresol. 
Crowns,  cantilever,  use  of,  352,  611 


Crowns,  loss  of,  by  caries,  299,  352,  Fig. 
300     ' 
in  root  treatment,  448 
removal  of,  501,  509 
temporary,  510 
use  of,  352 
Cup,  gum,  use  of,  548 

rubber,  use  of,  642 
Curette,  use  of,  562,  616,  774 
Cusps,  supplemental,  181 
Cysts,  associated  with  apical  conditions, 
539,  556 
causes  of,  188,  544 
dentigerous,  117,  188 
dermoid,  189 

teeth  in,  189 
impacted  teeth  as  cause  of,  117,  128 
varieties  of,  117,  128,  544 


Deapness,  dental  cause  of,  578,  715 
Decalcification  of  dentin  in  dental  caries, 
280 
of  roots,  89 
Degeneration,  33 
atrophic,  60 
calcareous,  62,  377,  417 
coUoid,  59,  427 
fatty,  57,  424 

of  pulp,  424 
fibroid,  421,  599 
forms  of,  57 
granular,  58 
of  gum  margins,  625 
of  nerve-end  of  pulp,  427 
of  pericementum,  589,  599 
of  pulp,  420 
Dehj'drator,  use  of,  324 
Dens  in  dente,  175 
Dentalone,  use  of,  391 
Dentifrice,  use  of,  755 
Dentin,  destruction  of,  89,  199,  214,  280 
cement  substance  of,  141 
secondary,  361 
development  of,  141 
globiiles,  141 

granular  laver  of.  Fig.  134 
histology  of.  Figs.   122,   123,   133, 

134,  135 
hypersensitivitj'  of,  209,  304 
after  replantation,  367 
anatomical  basis  of,  304 
caiises  of,  306 
diagnosis  of,  311 
pathology  of,  306 
symptoms  of,  309 
treatment  of,  311 
interglobiilar  spaces  in,   151,  Figs. 

133,  297 
intertubular  substance  in,  142 
hnes  in,  153 
malformations  of,  microscopic,  150 


808 


INDEX 


Dentin,    nutritional     relation     of,     to 
cementum,  147 
recalcification  of,  343 
repair  of,  229,  366 
resorption  of,  89,  400,  581 
secondary,  361 

bacterial  penetration  of,  368 
staining  of,  232,  293 

by  putrefaction,  490,  505 
stains  of,  treatment  of,  232,  505 
tubes  of,  Figs.  122,  123 
tubular  calcification  of,  359 
tumor  of,  365 
Dentinal  fibrils,  141 
in  enamel,  144 
in  interglobular  spaces,  151 
papilla,  141 
Dentition,  63 

bottle  feeding  in,  73,  86 

cause  of,  64 

constitutional  states  modifying,  85 

normal,  63,  87 

pathological,  69,  91 

as  cause  of  epilepsy,  71 

convulsions  in,  74,  107 

diagnosis  of,  73 

diet  in,  79 

headache  in,  74 

hemophilia  in,  30,  77 

hemorrhage  after,  76 

intestinal  compUcations  in,  72, 
78 
feeding  after,  79 

lancing  in,  75 

nervous  disturbances  in,  73 

paralysis  in,  75 

prophylaxis  of,  759 

pulmonary  disturbances  in,  75 

rickets  in,  86 

scurvy  in,  86 

shock  in,  after  lancing,  77 

skin  disorders  in,  75,  78 

strabismus  in,  75 

symptoms  of,  70,  71 

syphilis  in,  85 

systemic    conditions   influenc- 
ing, 70,  85,  106 

treatment  of,  75 
periods  of,  67 
process  of,  66 
second,  87 

cancer  from,  1 10 

disorders  of,  103 

irregularities  of,  92,   94,    101, 
106 

necrosis  in,  106 

pathological,  106 
symptoms  of,  106 
Depletion  of  gum,  405 
of  pulp,  395,  404 
Derivation,  use  of,  405,  527,  570,  572 
Dermoid  cysts,  189 

teeth  in,  189 
Development  of  face,  133 


Development  of  teeth,  141 
Devitalization  of  pulp,  435 
Devitalizing  fiber,  use  of,  404,  430,  441 
Dewey,  views  of,  555 
Diabetes  mellitus,  270 
Diagnosis,  definition  of,  18 
Diapedesis,  28,  39,  393 
Diathesis,  hemorrhagic,  29 
Dichloramin-T,  use  of,  467,  493,  494, 

497 
Diet,  dental  caries  and,  253 

in  pathological  dentition,  79 
Dilaceration  of  teeth,  177 
Diphtheria,  725 

Discoloration  of  teeth,  488,  490,  505 
Disease,  basis  of,  17 

causes  of,  18 

cUnical  history  of,  18 
Disking  teeth,  337,  357 
Dislocation  of  teeth,  600 
Distomolar,  195 
Disuse  of  teeth,  595 
Dobell's  solution,  use  of,  552 
Donaldson  cleaners,  use  of,  451 
Dover's  powders,  use  of,  528 
Downie  broaches,  use  of,  452,  500 
Drill,  Gates-Glidden,  use  of,  455 

spear,  use  of,  450,  525 
Drugs,  intoxication  by,  618 
Dry  cups,  use  of,  548 

socket,  530,  579 
Dryness,  use  of,  323,  336 
Dunn  syringe,  use  of,  682 
Dwarfism  of  teeth,  167 
Dystrophies  of  teeth,  133,  155 


E 


Ear.  disease  of,  from  dental  cause,  578, 

715 
Eburnation,  210 

in  dental  caries,  292 
Ecchymosis,  28 
Eczema,  735 
Electricity  in  pulp  putrefaction,  496 

as  test,  485 

uses  of,  783 
Electrolysis,  327,  788 
Electrolytic  medication,  496,  788 
Embalming  paste,  use  of,  475 
EmboU,  septic,  27,  743 
EmboUsm,  27 
Embryology  of  face,  133 

of  teeth,  141 
Emetin,  use  of,  684,  688 
Emigration  of  corpuscles,  37 
Emphysema  of  cheek  from  air  pressure, 

504 
Empyema  of  antrum,  542,  550,  717 
Enamel,  agenesia  of,  166 

curve  in  temporary  teeth,  150 

in  dental  caries,  273 

dentinal  fibrils  in,  144 


INDEX 


sod 


Enamel  development  of,  141 

formation  of,  effect  of  exanthemata 

upon,  159 
fracture  of,  224 
globules,  141 
histology  of,  142 
hypoplasia  of,  158 
imbrications  of,  148 
interprismatic  cement,  141 
lines  of  Schreger  in,  148 
malformation  of,  macroscopic,  142 

microscopic,  143 
mottled,  155 
nodule,  179 
opaque  spots  in,  155 
organ,  141 

use  of,  306 
relation  of,  to  cementum,  306 
resorption  of,  214 
rod,  141 

sensitivity  of,  310 
stains  upon,  234  . 
striae  of,  147 
stripes  of  Retzius  in,  147 

of  Schreger  in,  148 
tubes,  Caush's,  145 
unusual  location  of,  179 
Endamcebse  as  cause,  651 
Endarteritis  obUterans,  623 
Endocarditis,  743 
Enemata,  use  of,  85 
EpitheUoma  from  teeth,  110,  209,  736 
Epizootic  stomatitis,  724 
Equinia,  725 
Ergot,  use  of,  31 
Erosion  of  teeth,  214 
acids  in,  216 

extraneous,  220 
diagnosis  of,  221 
effects  of,  221 

malnutrition  upon,  217 
treatment  of,  223 
Eruption  of  teeth,  causes  of.     See  Den- 
tition. 
Erythrophlein,  use  of,  447 
Escat's  nasal  anesthesia  method,  322 
Ether,  use  of,  312,  325,  357,  376,  428, 

433 
Ethyl  chlorid,  use  of,  325,  376,  420,  529, 

531 
Etiology,  definition  of,  18 
Eucalyptol,  use  of,  500,  613,  614,  627 
Euca-percha,  use  of,  472 
Eugenol,  use  of,  335,  391,  409,  430,  447, 

478,  539.     See  Oil  of  cloves. 
Euroform,  use  of,  445 
Europhen,  use  of,  445 
Evans'  root  drier,  use  of,  505 
Exanthemata,  726 

malformations  caused  by,  159 
necrosis  caused  by,  106 
Excess  of  teeth,  197 
Exercise,  use  of,  625 
Exostosis  of  alveolar  process,  578 


Extirpation  of  pulp,  447 
Extravasation  of  blood.     See  Blood. 
Exudates,  character  of,  35,  37,  38,  40,  44 
Eye,  disease  of,  from  dental  cause,  715 


Face,  development  of,  132 

embryology  of,  132 

fistula  on,  treatment  of,  553 
Faradism  as  test,  485,  791 

as  therapy,  785 
Fat,  degeneration  of,  57 

infiltration  of.  Figs.  25  and  61 

necrosis  of,  52 
Feeding  in  gingivitis,  625 

in  malformations,  148 

in  pathological  dentition,  79 
Ferric  chlorid,  use  of,  262,  532 
Fever,  532 

Fevers,  eruptive.     See  Exanthemata. 
Fiber,  arsenical,  use  of,  404 
Fibrin,  formation  of,  25 
Fibrosis.     See  Degeneration. 
Files,  root,  use  of,  452,  468 
FiUings,  combination  of,  342,  352,  356 
Fistulse,  44 

in  antrum,  542 

causes  of,  542,  544 

on  face,  threatened,  533 
treatment  of,  553 

healing  of,  548 

making  artificial,  528 

non-healing  of,  548 

packing,  531 

premature  closure  of,  531,  545,  548 
Flagg's  operation  for  scar,  554 
I  Flavors,  use  of,  336 
i  Fletcher's  carbolized  resin,  use  of,  350 
Flexion  of  teeth,  178,  184 
Floss  silk,  use  of,  750,  753 
Fluctuation,  45 
i  Food  supply,  abnormal,  18 
Foramina,  delta-Hke,  454,  475 

open,  472,  504 
1  Formaldehyde,  action  of,  upon  products 
of  putrefaction,  499 

irritation  from,  500,  609 

uses  of,  409,  430,  467,  482,  495,  539, 
546,  614 
I  Formocrescl,  use  of,  409,  430,  495,  498, 

539,  546,  563 
Formopercha,  use  of,  472 
Fourth  molar,  195 
Fowler's  solution,  use  of,  616 
Fracture  of  alveolar  process,  600 

of  teeth,  225,  492 
repair  of,  229 
treatment  of,  229 
Freezing,  use  of,  434 
Fungous  gum,  419 
Furimculosis,  744 
Fusion  of  teeth,  169 


810 


INDEX 


G 

Gall-stones,  origin  of,  62,  630 
Galvanism  as  test,  485 
Gangrene,  51,  481 

dry,  51,  482 

moist,  51,  487 

discoloration  from,  505 

of  pulp,  481 
dry,  482 
moist,  487 
partial,  525 
Gaultheria,  oil  of,  use  of,  614,  683 
Gemination  of  teeth,  175 
Geranium-formol,  use  of,  498 
Germicides,  efficiency  of,  493,  793 
Giantism  of  teeth,  167 
Gingivitis,  603 

antiseptic  washes  in,  613 

astringent  washes  in,  613 

deeply  seated,  616 

interstitial,  616 

marginal,  604 

systemic  causes  of,  618 
Glanders,  725 

Glands,  pericemental.  Fig.  573 
Glycerin,  use  of,  85,  324,  613,  614 
Glycerophosphates,  use  of,  223 
Glycogen  in  caries,  254 
Glycothymoline,  use  of,  614 
Gonorrhea  of  mouth,  610,  734 
Gout,  700 

Grafting  sponge,  use  of,  473 
Granulations  in  regeneration,  52 
Granulomata,  488,  491,  497,  513,  555 

radiography  in,  562 

systemic  complications,  557 
Greenfield's  artificial  root,  625 
Gihnore  attachment,  594 
.Grippe.     See  Influenza. 
Grooved  teeth,  159 
Guards,  use  of,  527 
Guillotine,  gum,  111 
Gmn,  anatomy  of,  604 

function  of,  625 

fungous,  419 

hyperplastic,  419 

laceration  of,  601 

lancing  of,  75,  531 

marginal  atrophy  of,  625 
Harlan's  method  in,  626 

sarcoma  of,  419 

tissue,  action  of  arsenic  on,  528 
Gutta-percha,    eucalyptol   solution   of, 
use  of,  472 

solvents  of,  500 

use  of,  339,  345,  348,  352,  355,  390, 
467,  469 


Hair,  teeth  and,  189,  193 
Hahsteresis  ossium,  50,  623 
Hamamehs  distillate,  use  of,  531,  570, 
614 


Hands,  sterilization  of,  796 
Hare-lip,  138 

Harlan's  method  in  atrophy,  626 
HartzeU,  Henrici,  views,  488,  555 
Headache  from  dental  diseases,  128,  746 
in  dentition,  74 
from  impaction,  128 
Healing  of  tissue,  52 
Heat  in  inflammation,  40,  411,  533 

use  of,  325,  336,  484,  531,  601,  616 
Hemoglobin,  derivatives  of,  29,  505 
HemophiUa,  29 

in  dentition,  30,  77 
Hemoplastin,  use  of,  32 
Hemorrhage,  acetam'hd  as  cause  of,  30 
after  extraction,  601 

pulp  removal,  431 
treatment  of,  30 
varieties  of,  24,  28 
Hemorrhagic  diathesis,  29,  77 
Herpes  labiaUs,  735 

zoster,  735 
Hertwig,  root  sheath  of,  152,  180,  556, 

Figs.  186,  575,  576 
Heteroplasty  following  amputation  of 

natural  roots,  671 
High-frequency  current,  550,  684,  786 

as  a  test,  484 
Hot  water,  use  of,  325,  531,  601,  616. 

See  Heat. 
How  appUance,  use  of,  466 
Howe  on  caries  bacteria,  250 

silver  root  filling,  475,  477,  493,  497, 
548 
Howship's  lacunae,  584,  Fig.  17 
Hutchinson's  teeth,  160 
Hydrogen  dioxid,  78,  87,  103,  110,  238, 
239,  409,  420,  456,  534,  546, 
549,  554,  615,  642 
dangers  of,  541 
Hydronaphthol,  use  of,  342,  344,  349, 

613,  629 
Hygiene,  definition  of,  19 
Hyoscyamin,  use  of,  314 
Hyperacidosis,  209,  213,  218,  621,  700 
Hypercementosis,  155,  210,  575 

reflex  neuroses  from,  578,  710 
Hyperemia,  arterial,  34,  37 
degrees  of,  34 
from  arsenic,  435 
of  pulp,  380 

arterial,  380 

deyitahzation  in,  392 

from  electric  action,  387 

from  hypercementosis,  578 

idiopathic,  387 

reflex  in  constructive  disease, 

363 
thermal  toleration  in,  392 
venous,  392 

devitahzation  in,  438 
from  hanging,  395 
suffusion  from,  393 
as  a  resistance  to  infection,  34 


INDEX 


811 


Hyperemia,  results  of,  34,  35 

symptoms  of,  34,  395 

venous,  34,  37,  392 
Hypernutrition,  19 
Hyperplasia  of  gum,  419 

of  pulp,  415 
Hypersensitivity  of   dentin,    304.     'See 

Dentin. 
Hypertrophy  of  pulp,  415 
Hypnotism,  use  of,  314 
Hyponutrition,  19 
Hypophosphites,  use  of,  400 
Hypoplasia,  133 

of  enamel,  150,  158 
Hysteria,  314 


IcHTHTOL,  use  of,  726 
Immiinity  to  caries,  266 

acquired.     See  Vaccines. 
Impaction  of  teeth,  108,  115,  116 
death  of  pulp  from,  128 
diagnosis  of,  129 
headache  from,  128 
necrosis  from,  121 
nervous  and  cerebral  disturb- 
ance from,  128 
neuralgia  from,  126 
resorption  of  roots  from,  129 
suppurations  from,    109,    123, 

127 
symptoms  of,  126 
treatment  of,  129 
Implantation,  781 
Inclusion  of  teeth,  175 
Indican  as  an  index  for  malnutrition,  620 
Indol,  489,  620 
Infants,  feeding  of,  79 
Infarction,  27,  28 

of  pulp,  393,  420 
Infection,  classes  of,  41 

from  foci,  557,  694,  741,  747 
from  the  mouth,  741,  748 
general  septic,  47,  741 
of  mouth,  721 
Infiltration,  61 
calcareous,  62 
fatty,  57 

pigmentary,  28,  61 
Inflammation,  36.    See  Impaction,  Pul- 
pitis, Gingivitis,   Pyorrhea,  Sto- 
matitis. 
bacteria  in,  36,  41,  47 
bloodletting  in,  405,  531,  534,  666 
of  bone,  48 
catarrhal.  Fig.  11 
causes  of,  36 
coagulation  in,  38 
derivation  in,  392,  405 
elements  in,  38 
exudates  of,  38,  40 
infective,  41 
necrosis  in,  42 


Inflammation,  pathology  of,  36 
of  puJp,  396 

chronic,  415 
resolution  in,  42 
simple,  36 
stimulation  in,  528 
suppurative,  42 
symptoms  of,  40,  45,  46 
zones  in,  39,  45 
Influenza,  385,  717 

dental  pain  from,  717 
Injury  of  teeth,  mechanical,  224 
Insanitv  from  dental  disease,  128,  578, 

715,  746 
Insomnia    from    dental    disease.     See 

Focal  Infections. 
Instnmients,  steriHzation  of,  799.     See 

Asepsis. 
Insulator,  the,  231 
Interglobular  spaces,  151 
Intermaxillary  bone,  failure  of  develop- 
ment of,  138 
formation  of,  136 
Intestinal  compHcations  in  pathological 

dentition,  72,  78 
Intoxications.     See     Acidosis,     Drugs, 

Sepsis,  Septicemia,  Toxemia. 
Intubation  of  root,  509 
Involucrum,  51 

lodin,  dental,  tincture  of,  391,  420,  504, 
572,  749 
trichlorid  of,  use  of,  110,  111,  466, 

756 
use  of,  107,  111,  238,  334,  420,  446, 
465,  531,  614,  616,  642,  683,  800 
Iodoform,  use  of,  344,  349,  467,  469,  475, 

476,  500,  541,  546,  549 
lodoglycerol,  use  of,  531,  552,  683,  800 
Ions,  definition  of,  327,  787 

use  of,  684 
Ionization,  use  of,  496,  563,  787 
Iritis,  746 
Iron,   chloride  of,  tincture  of,  use  of, 

262,  532,  758 
Ischemia,  33 
Ivy,  views  of,  556 


Jaw,  development  of,  133 

growth  of,  cause  of,  89 
Jodoformagen,  use  of,  344,  345,  349,  390, 

391,  447  . 

Joining  of  teeth,  589,  592 
Jugulation  of  pulp,  395 


Kaxium  natriima,  use  of,  465,  503,  572 
Kowarska's  paste,  571,  673 
Krameria,  use  of,  613 


812 


INDEX 


Laceration  of  soft  tissues,  601 

Lactic  acid,  use  of,  682 

Lacunffi,  Howship's,  584,  Fig.  17 

Lancing,  use  of,  75,  110,  531 

Lanolin,  use  of,  730 

Laudanum,  use  of,  107,  601 

Lavoris,  use  of,  614 

Laxatives,  use  of,  624 

Lead,  oral  effects  of,  622 

Leeches,  use  of,  527 

Lemon  juice,  use  of,  87,  220,  336,  694 

Leprosy,  739 

Leukemia,  23,  268 

Leukocytosis,  23,  46 

Leukoplakia  buccalis,  736 

Lichen  planus,  737 

Ligature,  iise  of,  30,  570 

Light,  electric,  use  of,  301,  484,  533,  551 

Lime-water,  use  of,  758 

Linings,  use  of,  343 

Listerine,  use  of,  79,  531,  614 

Lithia  salts,  use  of,  625 

Looseness,  effects  of,  569 

Ludwig's  angina,  110,  739,  742 

Lugol's  solution,  552,  615 

Lupus  of  mouth,  734 

Luxation  of  teeth,  599 

Lymph,  coagulable,  504 

Lymphadenitis,  744 

Lymphangitis,  744 


M 


Magnesia,  milk  of,  use  of,  223,  336 

sulphate  of,  use  of,  111,  527 
Magnet,  use  of,  465 
Malaria,  dental  pain  from,  385,  716 
Mafformations,  133 

dystrophic,  155 

macroscopic,  155 

microscopic,  143 

non-dvstrophic,  167 

of  roots,  182,  460 
Malnutrition,  causes  of,  18,  741,  745 
Malocclusion  of  teeth,  98,  569,  588,  593 
classification  of,  98 
prophylaxis  of,  758 
Malpositions  of  teeth,  115 
Massage,  use  of,  109,  532 

\dbratory,  533,  785 
Mastication  in  therapeutics,  626 
MaxiUse,  embryology  of,  133 
Measles,  effect  of,  106,  159 
Mechanical  injury  of  teeth,  224 

union  of  teeth,  175.    See  also  Frac- 
ture. 
Meckel's  cartilage,  140 
Melancholia  from  dental  disease,   128, 

746 
Menthol,  use  of,  323,  325,  334,  391,  409, 
539,  579,  613,  717 


Menthol-phenol,  use  of,  391,  572 
Mercury,  bichlorid  of,  use  of,  456,  469, 
532,  572,  615,  756 
-    as  cause  of  stomatitis,  572,  721 

oral  effects  of,  106,  572 

succinamide  of,  561,  689 

Talbot's  experiments  on  dogs  with, 
568,  573,  619 
Metallic  stains,  252 
Metastasis,  27,  44,  47,  48,  743 
Methyl  chlorid,  use  of,  325,  420 
Microorganisms,  as  disease  causes,   18 
Milk  of  magnesia,  use  of,  223,  336  ■ 

modified,  79 
Molars,  pathological  dentition  of,  106 
Morphin,  use  of,  313,  405,  527 
Motor  reflexes  from  dental  disease,  714 
Mouth,  actinomycosis  of,  734 

asepsis  of,  747,  799 

breathing,  102 

development  of,  133 

gangrene  of,  109,  725 

gonorrhea  of,  610,  734 

infections  of,  719 

inflammation  of.     See  Stomatitis. 

lamp,  use  of.     See  Light. 

sepsis  from,  741 

soft  tissues  of,  laceration  of,  601 

sterihzation  of,  613,  799 

syphiUs  of,  728 

tuberculosis  of,  733 

washes,  application  of,  613,  755 
Mucin  in  dental  caries,  244,  263,  269 

in  saUva,  631 
Mucous  anesthesia,  321 

membrane,  glycogen  in,  265 
Mmnmification  of  pulp,  476 
Mummifving  paste,  arsenic  and,  445 

use  of,  475,  476 
Myers'  sjTinge,  use  of,  330 
Myrrh,  tincture  of,  use  of,  616 


N 


Nasal  anesthesia  method,  321 

obstructions,  99,  102 
Nasmyth's  membrane.  Figs.  186,  577 

in  dental  caries,  279 
Necrobiosis,  50,  57 
Necrosis,  50 

after  extraction,  602 
of  alveolar  bone,  530 
of  bone,  50 

arsenical,  444 

from     alveolodental     abscess, 

553,  563 
from  syphihs,  563,  732 
coagulation,  52 
etiology  of,  50 
of  fat,  52 

from  exanthemata,  106 
from  mercury,  106,  572 
from  typhoid  fever,  106 
liquefaction,  52 


INDEX 


813 


Necrosis,  phosphorus  and,  737 

varieties  of,  42,  44 
Needle,  hypodermic,  315 
breakage  of,  321 
Neoplasm  of  pulp,  426 
Neosalvarsan,  use  of,  690 
Nephritis,  744 
Nerv-e,  fifth,  707 

sensor^',  of  face,  707 
supply,  abnormal,  18 
vasomotor,  33,  380 
Nervocidin,  use  of,  326,  434 
Nervous  disturbances  in  dental  disease, 
746 
in  dentition,  74,  107 
Neuman,  sheath  of,  Figs.  122,  123 
Neiu-algia,  cause  of,  109,  299,  705 
from  h^^percementosis,  578 
from  hypersensitive  dentin,  706 
from  impacted  teeth,  712 
from  pericemental  disease,  710 
from  pulp  disease,  708 
from  root  resorption,  589 
treatment  of,  717 
Neuritis,  744 
Neiiroses,  reflex,  705 
Nitric  acid,  use  of,  335 
Nitrous  oxid  gas,  use  of,  312,  404,  428, 

531 
Nodule,  cemental,  184 
enamel,  179 
in  pulp,  369 
Noma,  109,  725 
Non-conductors,  uses  of,  340 
Nose  and  dental  disease,  543 
Novocain,  use  of,  110,  315,  390,  391,  429 

431,  438,  531,  572,  601 
Number  of  teeth,  variations  in,  192 
Nutrition,  basis  of,  19 
deficiency  of,  33 


OcEAK"  water,  use  of,  552 
Odontalgia,  phantom,  712 
Odontoblasts,  67,  141 

atrophy  of,  364 

relation  of,  to  sensory  nerves,  304 
Odontomata,  184 
Odor  as  a  test,  484 
OUgocjiihemia,  21 
Ohve  oil,  use  of,  78 
Opium,  use  of,  78,  79,  109 
Opsonic  index,  raising  of,  690 
Orange  juice,  use  of,  87 
Orthoform,  use  of,  334,  351,  445,  603 
Oscillation,  38 
Osteitis,  condensing,  49 

rarefying,  48 
Osteodentin,  367 
Osteomalacia,  623 
Osteomyehtis,  48 
Osteoporosis,  48 


Osteosclerosis,  49,  120 
Overarch  bar,  use  of,  592 
Overuse  of  teeth,  588 
Oxahc  acid,  use  of,  239 
Ox3'gen,  nascent,  use  of,  507 


Pain,  dental,  from  other  sources  than 
dental,  716 
postextraction,  579,  601 
Palate,  cleft,  cause  of,  137 
Paraffin,  use  of,  466,  494,  509 

solvent  of,  500 
Paraform,  use  of,  476 
Paraglossus,  the,  213 
Paralysis  in  dentition,  75 

from  dental  disease,  578 
Paramolar,  195 
Pathology,  basis  of,  19 

dental,  definition  of,  17 
general,  defijiition  of,  17 
Peck's  anesthetic  method,  322 
Pedilu"\dum,  hot,  use  of,  527 
Perforation  hy  accident,  464 
by  caries,  298,  350 
as  cause  of  abscess  of  root,  550 
filhng  of,  464,  479 
Pericemental  abscess,  698 
Pericementitis,  511.     See  also  Pyorrhea 
alveolaris. 
acute,  septic,  apical,  512 

extraction  in,  529 
beginning  at  giun  margin,  605 
chronic,  septic,  apical,  535,  567 
non-septic,  376,  568 
results  of,  574 
symptomatic,  572 
septic  at  bifurcations  of  roots,  567 
symptomatology  of,  511 
traiunatic,  568 
Pericementum,  degeneration  of,  589 
fibroid,  599 
development  of,  143 
diseases  of,  511 
fibrosis  of,  599 
glands  of,  556 

histology'  of.  Figs.  575,  576,  577 
overuse  of,  588 
Periostitis,  48 

maxillar}^  545 
Petechia,  28 
Phagocj'tosis,  604 
Phantom  odontalgia,  712 
Phenacetin,  use  of,  405 
PhenandjTie,  use  of,  391 
Phenobromate,  use  of,  313 
Phenol  camphor,  use  of,  323,  391,  539, 
572,  601,  683 
sodique,  use  of,  78,  107,  601,  614, 

756 
use  of,  332,  334,  391,  434,  723.  See 
Carbolic  acid. 


814 


INDEX 


Phenolsulphonic  acid,  use  of,  497,  546, 

563 
Phosphor  necrosis,  737 
Phosphorus,  use  of,  223 
Physical  condition,  alsnormal,  IS 
Picks,  Rhein's,  use  of,  452,  466 
Pigmentary  infiltration,  393,  438,  506 
Pigmentation  in  dental  caries,  293 
Pigments  in  tissue,  28 
Pilocarpin,  oral  effects  of,  573 
Pins,  removal  of,  501 
Piscidia  erythrina,  use  of,  313 
Pitted  teeth,  159 
Plantation,  777 

mode  of  attachment  in,  587 

resorption  after,  587 
Plaques,  microbic.     See  Caries. 
Plaster  of  Paris,  use  of,  349 
Plethora,  21 
Pocket  for  arsenic,  405 
PodophyUin,  use  of,  624 
Pointing,  43,  45,  531 
Porcelain  inlays,  use  of,  345,  627 
Porte-pohsher,  use  of,  645,  750,  754 
Potassium  bitartrate,  use  of,  756 

bromid,  use  of,  213 

carbonate,  use  of,  324 

chlorate,  use  of,  78,  87,  616,  756 

hydrate,  use  of,  332 

iddid,  use  of,  391,  573,  621 

sulphocyanate,  use  of,  336 
Potassocain,  use  of,  325 
Poultices,  danger  of,  533 
Powder,  tooth,  use  of,  755 
Pregnancy,  dental  pain  from,  717 
Pressure  anesthesia,  326,  330,  404,  410 

hemorrhage  after,  431 
Procain,  use  of.     See  Novocain. 
Process,  alveolar,  fractxu-e  of,  600 
Prognosis,  definition  of,  18 
Prophylaxis,  19,  596,  749,  751 
Protozoa  as  disease  causes,  653 
Pulp,  abscess  of,  410 

access  of  bacteria  to,  386,  397 

action  of  arsenic  on,  521 

ahnost  exposed,  342 

anesthesia  of,  429 

atrophy  of,  364,  423  - 

capping  of,  348 

cavity,  dupH cation  of,  175 

forms  of,  Figs.  418,  419,  420 

constructive  diseases  of,  359 

death  of,  from  impaction,  128 

degeneration  of,  368 

calcific,  377,  414,  417 
cloudy,  424 
colloid.  Fig.  388 
fatty,  424 
fibroid,  420 
nerve,  Fig.  389 

depletion  of,  395 

destructive  diseases  of,  380 

devitaUzation  of,  425,  447 

digestion  of,  479 


Pulp,  exposure  of,  346 
extirpation  of,  447 
fungous,  416 
gangrene  of,  481 
partial,  409 
hyperemia  of,  380 
arterial,  380 

devitalization  in,  392 
from  electric  action,  387 
idiopathic,  385 
pericementitis  from,  388 
thermal  toleration  in,  392 
uterus     and    bladder    as 
cause  of,  711 
from  arsenic,  4.35 
test  for,  389 
venous,  389 

suffusion  in,  438 
hyperplasia  of,  415 
infarction  of,  422 
inflammation  of,  396.    See  Pulpitis. 

chronic,  415 
jugulation  of,  395 
knocking  out,  446 
moist  gangrene  of,  487 
mummification  of,  476,  482 
neoplasm  of,  427 
nodules,  369,  386 
arsenic  and,  375 
reflexes  from,  375 
polypus  of,  416 
protection  of,  343 
puncturing  of,  395,  404,  410,  414 
putrefaction  of,  409,  487 
removal  of,  428 
partial,  477 

special  methods  of,  446 
replantation  of,  vitality  after,  367 
sclerosis  of,  415 
sedation  of.     See  Sedatives-, 
suffusion,  393,  438 
suppuration  of,  406 
thermal  tolerance  of,  392 
thrombosis  of,  422 
toughening  of,  455 
ulceration  of,  407 
vessels,  paralysis  of,  396 
vitality  of,  tests  for,  483 
Pulpitis,  396 
acute,  398 
chronic,  415 

from  pyorrhea,  397,  663 
hyperplastic,  415 
reflex  disorder  from,  70S 
resorption  of  dentin  in,  400 
Pumice,  iise  of,  643 
Puncture  probe,  446 
Puncturing  of  pulp,  395,  404,  410,  414, 

446 
Purpura  hemorrhagica,  741 
Pus  formation,  42 

varieties  of,  44 
Putrefaction  of  pulp,  487 
Pyemia,  47 


INDEX 


815 


Pyogenic  calculus,  544,  556,  628 
Pyorrhea  alveolar  is,  649 

abscess  secondary  to,  664,  698 
beginning  with  a  marginal  gin- 
givitis, 657 
Bier's  hyperemia  in,  685 
in  bifurcations  of  roots,  670 
breath  in,  669 

bridge  and  plates  in,  678,  682 
causes  of,  649,  659 
cHnical  history  of,  656,  659 
dental  caries  and,  665 
diagnosis  of,  662 
endarteritis  in,  663 
gum  incision  in,  669 
heteroplasty  of  roots  in,  671 
interstitial  gingivitis  in,  660 
h\dng  pulps  and,  661,  665,  670 
looseness  in,  661 
not  dependent  upon  calculus, 

696 
oral  catarrh  in,  662 
pathology  of,  637 
predisposition    to,    569,    572, 

599,  607,  625 
prevention  of  motion  in,  672 
prophylaxis  in,  666,  686 
radiography  in,  662,  761 
recurrence  of,  687 
replantation  in,  685 
root  amputation  in,  670 
spHnts  for  use  in,  673 
surgery  in,  669 
systemic  effects  of,  694 
treatment  of,  666 

medicinal,  682,  688 
Pyrozone,  use  of,  238,  438,  465,  503,  507 


QuiNiN,  use  of,  313,  405,  527,  532,  719 


R 

Rachitis,  86 

effects  of,  150 
Radiography,  761 

as  a  test,  487,  531,  538,  562,  578, 
'587,  662 

of  root  canal.     See  Root  and  Canal. 
Raisin,  roasted,  use  of,  528 
Rapid  breathing,  use  of,  314 
Recalcification  of  dentin,  343 
Reflex  action,  385 

disorders  of  dental  origin,  705 
of  systemic  origin,  718 

neuroses,  705 
Regeneration  of  tissue,  52 
Removable  crowns,  509 
Repair  of  dentin  and  cementmn,  229 
Replantation,  550,  777 

of  pulp,^vitaUty  after,  367 


Replantation,   secondary   dentin   after, 
367 
of  teeth,  777 
Resistance  to  infection,  impaired,  745 
Resolution,  42 

Resorption  of  bone,  48,  50,  583,  623 
of  enamel,  214 
perforation  by,  92,  400 
of  permanent  roots,  581 
of  temporary'  roots,  89 
Rest,  surgical,  527,  570 

use  of,  32,  570,  593,  625 
Retention  of  teeth,  92.     See  Impaction. 
Retzius,  stripes  of,  in  enamel,  147 
Rheumatism,  745 
Rhigolene,  use  of,  325 
Ringer  solution,  use  of,  315 
Robinson's  remedy,  use  of,  332,  336,  339 
RoUin's  knife,  529 

Root,  amputation  of,  670,  671,  771,  776 
artificial,  781 
buried,  299 

calcification  of,  Figs.  35,  50 
canal,  accidents  in  opening,  464 
anatomy  of,  452,  456 
asepsis  of,  448 
electrical  disinfection  of,  496, 

788 
fining  of,  466,  479,  534 
inaccessible  foramina  of,  452 
loss  of  continuity  of,  462 
radiography  of,  448,  453,  467, 

469,  561,  764 
with  open  foramina,  472 
development  of,  67,  93 
drier,  Evans',  use  of,  446 
end  capping,  469,  471 
extraction  of,  in  hypercementosis, 

578 
filling,  disappearance  of,  474 

removal  of,  500 
fracture  from  putrefaction,  492 
fusion  and  concrescence,  169,  171 
implantation  of,  781 
intubation,  509 
long  and  short,  168 
loss  of,  by  caries,  353,  462 
malformations  of,  182 
multiple,  183 

perforation,  298,  350,  464,  479,  550 
permanent,  formation  of,  93 

resorption  of,  581 
repair  of,  324 
replantation  of,  647 
resorption  of,  89 

of  permanent,  581 
sterilization  of,  448,  493,  503 
systematic  stopping,  540 
temporary,  resorption  of,  89 
transplantation  of,  779 
Rose  geranium,  oil  of,  use  of,  498 
Rubber  band,  use  of,  753 
cup,  use  of,  548,  641 
sore  mouth  and,  724 


816 


INDEX 


Saccharin,  use  of,  78,  131,  613 
Salicylic  acid,  use  of,  613 
Saliva,  analysis  of,  631 

in  dental  caries,  263,  269,  270 
glucose  in,  268 
increased  flow  of,  757 
lack  of,  264 

relation  of  acid  food  to,  756 
Salivary  calculus,  630.     See  Calculus. 
Salivation  by  mercury,  572 
Salol,  use  of,  79,  532 
Salt,  309,  402,  601,  683 
Salvarsan,  use  of,  615,  654,  690 
Sandarac,  use  of,  350,  420 
Sanguinary  calculus,  628,  647 
Scab,  healing  under,  56 
Scar,  threatened,  533 

tissue,  535 
Scarlet  fever,  effect  of,  106,  159 
Schreger,  stripes  of,  in  dentin,  154 

in  enamel,  148,  153 
Scissors,  gum,  use  of,  76,  111 
Sclerosis  of  pulp,  415 
Scorbutus,  738,  739 
infantile,  86 
oral  effects  of,  572,  738 
Scurvy. _   See  Scorbutus. 
Second  intention,  healing  by,  52 
Secondary  dentin.     See  Dentin. 
Sedation,  results  of,  19 
Sedatives,  use  of,  391,  404,  570,  572 
Seidhtz  powders,  624 
SeniUty  and  gums,  625 
Sensitivity  as  test,  483 
Sepsis,  general,  of  dental  origin.     See 
Infection, 
intoxication  from.     See  Infection. 
Septicemia,  44,  47,  48,  51,  106,  109 

from  apical  abscess,  519 
Sequestrum,  51 
Serres,  glands  of,  Fig.  515 
Serum  therapy,  31 
Serumal  calculus,  628,  647 
Shellac,  use  of,  131 
Shock,  77 
SiHcate  cements,  use  of,  166,  224,  238, 

339,  346 
Silver  cones,  use  of,  468 

nitrate,  use  of,  210,  331,  333,  338, 
355,    390,    420,    553,    615,   723, 
750 
root  filHng  (Howe),  475,  477 
Sinus,  44 

Size  of  teeth,  variations  in,  167 
Skin  eruptions,  75 
Slough,  52 

Soap,  use  of,  546,  624 
Sodium  biborate,  use  of,  613,  614 

bicarbonate,  use  of,  223,  332,  336, 

342,  344,  404,  625 
bromid,  use  of,  84,  213 
carbonate,  use  of,  797 


Sodium  chlorid,  use  of,  223,  333,  465, 
616,  625 
dioxid,  danger  of,  503,  572 

use  of,  238,  239,  332,  503,  507 
hydrate,  use  of,  332,  376 
ions,  use  of,  496 
phosphate,  use  of,  223 
potassium  and,  alloy  of,  use  of,  465, 
503,  572 
Somnoform,  use  of,  313,  428,  531 
Sphacelus,  52 

Spirochetes,  608,  654,  690,  740 
Sphnts,  use  of,  570,  595,  673 
Stains,  black,  236 
in  dentin,  237 
dyes  and,  236 
green,  234 
metalHc,  232 
non-metaUic,  234 
red,  237 
tobacco,  236 
treatment  of,  237 
Staphylococci,  406,  411,  655,  690 
Stasis  of  blood,  38 
Steresol,  use  of,  131 
Sterihzation,  dental,  793 
Stimulation,  effects  of,.  19 
Stomatitis,  719 
aphthous,  722 

classification  of  varieties  of,  719 
in  dentition,  70,  78 
diphtheritic,  725 
epizootic,  724 
equinis,  725 
from  drugs,  728 
from  eruptive  fevers,  726 
from  glanders,  725 
from  rubber  plates,  724 
gangrenous,  725 
gonorrheal,  610,  734 
herpetic,  735 
infective  catarrhal,  720 
mercurial,  573,  622,  721 

beneficial  effects  of  mercury  in, 
573 
simple  catarrhal,  720 
sjTnptomatic  catarrhal,  721 
syphihtic,  728 
tubercular,  733 
typhoid,  106 
ulcerative,  610,  721,  725 
Stopping,  systematic,  540 
Strabismus  in  dentition,  75 
Streptococci,  406,  411,  654 
Strontium  lactate,  use  of,  31 
Structure  of  teeth,  143,  261 
Strychnin,  use  of,  433,  718 
Subgingival  calculus,  628,  644 
Suffusion,  28,  393 
from  arsenic,  438 
from  hanging,  395 
from  Venous  hyperemia,  393 
Sugar  in  diabetes,  270 
Suggestion,  use  of,  312,  314 


INDEX 


817 


Sulphocyanate,  use  of,  270 

Sulphur,  use  of,  683 

Sulphuric  acid,  use  of,  239,  376,  430, 
446,  464,  465,  507,  549,  572,  682 

Sulphurous  acid,  use  of,  508 

Supernumerary  teeth,  197 

Supplemental  cusps,  181 

Suppuration  in  inflammation,  42 
of  pulp,  406 

Suprarenin,  use  of,  315 

SjTnptoms,  definition  of,  18 

Synostosis,  dental,  579 

Sjrphihs,  dental  pain  from,  385,  716 
hereditary,  162 
of  mouth,  728 

necrosis  of  bone  from,  563,  732 
oral  effects  of,  164,  573,  728 
stigmata  of,  160,  164,  181 

Syphilitic  teeth,  148,  160 

Syringes,  use  of,  315,  432,  546,  554,  682 

Systematic    stooping    of    troublesome 
root,  540 

Systemic  disease  from  focal  infection. 
See  Infection, 
prophylaxis  of,  758 


Talcum,  use  of,  78 

Talon  on  tooth,  182 

Tannin,  use  of,  30,  324 

Tapping,  as  test,  487,  539 

Tartasoi,  use  of,  682 

Temperature,  natural  tolerance  of,  392 

Temporary  stopping,  use  of,  467 

Tents,  use  of,  531,  533 

Tests  for  asepsis,  503 

for  pulp  vitaHty,  483 

Tetanic  spasm  from  teeth,  209 

Therapeutics,  basis  of,  17,  20 

Thoma,  view  of,  555 

Thrombosis,  25,  422 

Throphleol,  use  of,  447 

Thvmol,  use  of,  341,  344,  348,  349,  390, 
391,  396,  405,  409,  420,  614 

Thymophen,  use  of,  391 

Tic  douloureux,  375 

Tomes,  granular  layer  of.  Fig.  134  J 

Toxemia,  47,  73.     See  also  Septicemia. 

Translucency  as  a  test,  484 

Transparency  of  dental  structures,  199, 
290,  766 

Transparent  zone,  290 

Transplantation,  779 

Trephine,,  use  of,  529 

Treponema  paUidum,  728 

Trichloracetic  acid,  use  of,  420,  618,  682, 
723 

Trigemin,  use  of,  405,  528 

Trioxjonethylene,  use  of,  334 

Trophic  disturbance   from  dental  dis- 
ease, 716 


Tube  casts  in  dental  caries,  289 
Tuberculosis  of  mouth,  733 
Tubes  of  dentin,  Figs.  122  to  136 

of  enamel,  144 
Tubular  calcification,  359 
Tumors,  191 

dental  pain  from,  385 
Turkish  baths,  use  of,  629 
Typhoid  fever,  effect  of,  108,  268 


Ulceration,  42,  46 

of  pulp,  407,  410 
Union  of  teeth,  mechanical,  175 
Urates  in  pericementum,  699 
Uterine  disease,  dental  pain  from,  717 
Uvula,  bifid,  138 


Vaccine  therapy,    112,   532,  541,  554, 

690 
Vacuum  appHances,  546 
Vapocain,  use  of,  325 
Varnish,  use  of,  340 
Vascular  system,  disturbances  of,  21 
Vasomotor  nerves,  33 
Venous  hyperemia,  34,  37,  392 
Veratrin,  use  of,  109 
Vermifuges,  use  of,  214 
Vernas  lotion,  use  of,  614 
Vibration,  electric,  785 

use  of,  533,  785 
Vincent's  angina,  608,  615,  740 
Violet  ray,  484,  550,  785 


W 


Wall,  foUicle,  143 
Wassermann  test,  182 
Waste,  removal,  abnormal,  18 
Water,  boiUng,  as  germicide,  794,  797 

drinking  of,  625 

warm,  use  of,  339 
Wax,  use  of,  474 

Whisky,  use  of,  314.     See  Brandy. 
Wintergreen,  oil  of,  use  of,  336 
Wood  point,  use  of,  750,  754 


X-RAYS,  use  of,  684,  718.    See  Radiog- 
raphy. 
Xerostomia,  264 
Xylol,  use  of,1500 


818 


INDEX 


Zinc  cUorid,  use  of,  324,  331,  332,  336, 
340,  420,  431,  504,  572,  613,  614, 
615,  683 

cones,  use  of,  472 

iodide,  use  of,  614,  683 

ions,  use  of,  496,  787 

ointment,  use  of,  78 


Zinc  oxid  and  eugenol,  use  of,  345,  349, 
355,  390,  391,  479 
use  of,  344,  349 
oxychlorid  of,  use  of,  344,  345,  349, 

472 
oxj^phosphate,  use  of,  107,  340,  342, 

344,  346,  348,  355,  390,  499 
oxysulphate,  use  of,  326,  345,  349 
sulphate,  use  of,  391 
sulphocarbolate,  use  of,  683 


